Paul Krugman: The best places to get sick

April 17, 2005 8:52 AM

Paul Krugman: The best places to get sickA dozen years ago, everyone was talking about an American health care crisis. But then the issue faded from view: A few years of good data led many people to conclude that HMOs and other innovations had ended the historic trend of rising medical costs. But the pause in the growth of health care costs in the 1990s proved temporary. Medical costs are once again rising rapidly and the U.S. health care system is once again in crisis. So now is a good time to ask why other advanced countries manage to spend so much less than we Americans do, while getting better results.
posted by Postroad (67 comments total)

Arnold Kling takes on Krugman's nonsense.
posted by Kwantsar at 9:13 AM on April 17, 2005

Also from Kling.
posted by Kwantsar at 9:21 AM on April 17, 2005

Analysis and data from several countries - mostly European, but including the USA
posted by TimothyMason at 9:22 AM on April 17, 2005

The fact remains that if you don't have healthcare in the US and you get sick or injured: you go bankrupt. The UK system is far from ideal but it beats the hell out of that.

I'm kind of sick of seeing people who have health insurance and well paid jobs debate the merits of the US health care "system". It's not a national system it's a consumer product.

Sure it's great: if you have access to it, a lot of people don't. Medicare / Medicaid does not cater for working class and lower middle class people who are currently stuck between a rock and a hard place. If you have a previous medical condition your insurance premiums will start at $600-$1000/ month. Try paying for that on $25-30K a year, especially if you have kids.
posted by fshgrl at 9:23 AM on April 17, 2005

More and more its also true that if you do have insurance and get sick or injured you will still go bankrupt, or at least face a giant pile of bills.

When you were unconcious after the accident, you failed to direct the ambulance to an "in-network" facility? Shame, we will not pay but 20% now.

Your appendics is bad? Well you only have had this policy for 6 months, according to our rules thats a "pre-existing condition".

Or the worst is having a baby. It is normal now to not cover any maternity care of any kind until 1 year into your policy. So you got pregnant after switching jobs into a new policy? Get your checkbook out.

My point is that the problems of our healthcare system is not that there are so many people who are uninsured. Its much more messed up than that.
posted by H. Roark at 9:34 AM on April 17, 2005

My guess is, they don't have Republicans.

Okay, so that's generalizing, but as usual when I'm generalizing, I don't care.
posted by fungible at 9:34 AM on April 17, 2005

I agree with fshgrl, it really doesn't matter how good the US healthcare system is if you don't have insurance. I am personally very lucky myself right now as I have a good HMO that I pay nothing for provided by my company but what happens if I get laid-off? An given Friday's stockmarket, that may happen sooner than later. I know many people who don't have insurance and just cross their fingers that nothing bad happens since they just can't afford to buy it themselves.
posted by octothorpe at 9:35 AM on April 17, 2005

I don't know what the right answer is, but it seems like Kling's take is mostly things like:

"Cutler does not make any international comparisons. However, one can imagine that in other countries a larger share of high-risk pregnancies end up as miscarriages. Those countries will have higher fetal death rates, but probably will have lower measured rates of infant mortality."

"One can imagine" is not a fact-based argument. If it's true, that fact will show up in birth-weight statistics, which are available here.

France (in 1998) and Germany (in 1999) saw about 7% of infants born with low weight. The US saw 8% (in 2002). I think Kling has an overactive imagination.
posted by hammurderer at 9:35 AM on April 17, 2005

Why is the price of U.S. health care so high? One answer is doctors' salaries


As a medical student in the US, my only plea is that you wait until i've paid off my student loans before you start hacking away at doctor's salaries. After that, have at them.

Also, what fshgrl said.
posted by deliquescent at 9:36 AM on April 17, 2005

"Okay, so that's generalizing, but as usual when I'm generalizing, I don't care."

I knew Dave Barry and you, sir, are no Dave Barry.
posted by I EAT TAPES at 9:38 AM on April 17, 2005

I can't speak for the UK, but in Portugal the public health system is universal but that doesn't mean that those that need treatment are getting it. Waiting lists in public hospitals are long, and potentially life threatening. In Portugal, if you need good healthcare you pay for private insurance and go to a private hospital. This to say that IMHO, the discussion needs to focus not only on how universal health care is, but also on its quality (here's OECD take on it).
posted by joaovc at 9:43 AM on April 17, 2005

In Portugal, if you need good healthcare you pay for private insurance and go to a private hospital.

I've always wondered, in situations like that, if the public system also brings down the cost of private health care. I saw a private doc and was x-rayed once in Spain, and was amazed at how inexpensive it was.
posted by deliquescent at 9:47 AM on April 17, 2005

"The fact remains that if you don't have healthcare in the US and you get sick or injured: you go bankrupt. The UK system is far from ideal but it beats the hell out of that."

The only problem with this "fact" is 1) it's not true and 2) it's not better to wait, in pain and on queue, for treatment if you have the option to walk into any ED and get treated, as is required by federal law.
posted by Alwin at 9:49 AM on April 17, 2005

However, there are just a slew of mitigating factors that show US health care to be far above that of other countries.

First, consider demographics: high density health care is far more economic than in areas with lower densities. The US is very underpopulated, and yet we have health services spread far and wide.

Second, we *do* provide vast amounts of health care to the poor and indigent, including 2-3 Million *new* extreme poverty-level (illegal) immigrants each year. It is not the best, mostly acute medical response; and most of these type problems are both difficult to treat and expensive, but we do provide them with a level of free care beyond what Mexico could possibly provide, which is almost nothing. It can take anywhere from 5-20 years for these people to "tier-up" in the US health care system to the level of paying for services.

Third, across the board we have extremely stringent standards for sanitation not found in the rest of the first world. More and more, iatrogenic epidemics are affecting hospital systems outside of the US. And this level of cleanliness (and disposal) is very expensive.

Fourth, if there is a new technology, there is ready capital to fund it immediately, without excessive bureaucratic delay to look for funding. A market driven system delivers quickly, but at a premium price. Hospitals also compete for technologies that are often redundant in an area. If one hospital has the lates MRI, every other hospital in the area wants one.

Fifth, the HMO system has peaked in efficiency, and "better mousetrap" models, economically speaking, are rising. For example "cash only" physicians that deliver services at half the price of non-HMO physicians, but discriminate: no government paid, no insurance paid treatment. Also, there are "bearback" physicians, with shielded assets, who operate without malpractice insurance, but at significantly lower prices.

So in a way, with multiple systems, the market is replicating what is good about government-run systems, while adapting alternatives to the inherent flaws in such systems, and the flaws in existing free-market systems. Things change, and the free-market adapts to need.

The US attitude is "The best for the most, and something for everybody", which in the long run is a lot better than the "Mediocre for everybody" found in nationalized medicine.
posted by kablam at 9:57 AM on April 17, 2005

I think Kling and Krugman are both lightweights in a healthcare debate. They are both economists for kryssakes. And they are both engaging in spurious data abstractions to support their respective positions.

(mind you, I will take a lot of convincing to believe Kling's assertions that USA has more prem babies than other western countries - that just flies in the face of lower socioeconomic welfare realities and is offensively dismissing of the quality of care given to viable prem babies in other western countries. We in Oz spit on you Kling!)

fshgrl is right to bring up direct observations as a measure of effectiveness of healthcare. The major thing lacking in both those articles was qualitative data. It's a much more effective argument for change (although recent bankruptcy law changes are evidence to the contrary)

We keen outside observers of USA health wish you well. But it seems to me that history/politics and economics are going to prevent any attempts to nationalize healthcare to any great extent. I think that the reality is that any reforms will have be had by chipping at the margins. With such right-leaning politics entrenched, it's hard to see a way ahead. Perhaps concerned commentators, instead of scattergun ranting should just concentrate efforts on lobbying for changes to widen insurance coverage and forget about international comparisons and urges for structural changes to the health delivery system.

On preview kablam....from this vantage point I would have thought that it was 'the best for the rich and the rest can fight for the remainder'
And I suggest that those of us with quasi-socialist health care systems KNOW that all of our citizens will get good quality care. Yes there are waiting lists. Yes there are problems. But for the mostpart, I can guarantee that the vast majority of Oz people would assert that they receive excellent treatment. And they don't have to worry much about money in the process.
posted by peacay at 10:04 AM on April 17, 2005

Everyone keeps talking about how health care costs keep rising, but no one ever talks about why.

I think the reason is that baby boomers keep getting older, and being older, the cost more to keep healthy.

Discuss.
posted by delmoi at 10:05 AM on April 17, 2005

Also, Kling's first couple paragraphs are so jigonistic as to be unreadable.
posted by delmoi at 10:05 AM on April 17, 2005

Speaking of statistics, Kling's article in response to Krugman mentions the word "cabal" 10 times.
posted by funambulist at 10:09 AM on April 17, 2005

Arnold Kling takes on Krugman's nonsense

The first two paragraphs are a paranoid conspiracy rant in which he maintains on no evidence whatsoever that Krugman is the leader of a "cabal". He refers back to this cabal throughout the screed without ever having substantiated it.

The remainder of the article uses the phrase "I believe it is beyond reasonable doubt" any number of times to make peripheral claims based on dodgy data, most of it to do with per capita health care spending which as a single data point is fairly useless and wouldn't help his point even if it were useful. He then concludes that we don't know enough. Well, it's clear he doesn't know enough, and doesn't want to.

The only problem with this "fact" is 1) it's not true and 2) it's not better to wait, in pain and on queue, for treatment if you have the option to walk into any ED and get treated, as is required by federal law.

Are you suggesting that emergency rooms aren't filled with people waiting in pain? Do you seriously believe that you get prompt, quality health care in the ER, plus necessary followup treatment afterward? Are you suggesting that they won't be bankrupted by the costs? A goddamn aspirin will cost you fifty bucks in the ER. Do you not realize that recourse to the emergency room for people who get no preventative health care or non-emergency access to health facilities is part of the problem, not the solution you claim it is?
posted by George_Spiggott at 10:10 AM on April 17, 2005

I agree with fshgrl, it really doesn't matter how good the US healthcare system

as fshgrl noted, there is no US healthcare system. there are only healthcare consumer products. when you confine your verbal expression to the inside of the framing provided by the enemy, you forward the enemy's cause. there is no system. there is only predation.
posted by quonsar at 10:23 AM on April 17, 2005

I'm glad I wasn't the only one who noticed the usage of "cabal." It only took him three words to attempt to frame the other side of the debate that way. It seems to me that indicates he's someone who's less interested in an honest appraisal of the situation than he is in picking and choosing among facts and figures to meet his argument and calling the other guy names.

Alwin, you are ignoring that after someone visits the ER, they get a bill for thousands of dollars and, often enough, can't pay. That's what fshgrl is getting at.
posted by MegoSteve at 10:29 AM on April 17, 2005

You want to know why we spend (waste) so much money on health care? I think it is illustrated here. Drugs number 3, 5, 15, and 16 are proton pump inhibitors. For the top four PPI we paid 11.1 billion dollars. Add to that the fact that PPI are almost never necessary. Ranitidine, safer, and at one tenth the cost would work in 90% of the cases -- and from my experience, most people receiving this treatment never had any problems with stomach acid.
We pay too much for unnecessary drugs. Doctors are the focal reason, they don't like to admit that they buy into drug rep crap, but they do. If they didn't we'd be selling 1 billion dollars worth of PPI (mostly omeprazole which is cheap and belongs to this class).
posted by dances_with_sneetches at 10:33 AM on April 17, 2005

Isn't the point here that per capita, the US spends more public money on health care than Canada, the UK or France? I'm willing to accept that spare-no-expense private health care in the US is the best in the world, but without sacrificing that, can't the US administer a public system that would actually give universal coverage, seeing as other developed countries do it for less per capita? Why has this just turned into a public vs. private argument?
posted by [expletive deleted] at 10:37 AM on April 17, 2005

Alwin
Regarding your statement that health care related bankruptcy is not fact, it is true: the leading cause of bankruptcy in this country is health care costs. This country eats it's own while subsidizing those who clearly need no subsidizing (the rich and businesses with unearned tax refunds and waiver of tax responsibility).
Your data is deeply flawed and you need to acknowledge that. A 180% increase in bankruptcies in this country is nothing to be proud of and clear evidence of the predatory nature of this countries' lenders that is breaking the back of this country while driving it's population into a lifetime of indentured servitude.
posted by mk1gti at 10:42 AM on April 17, 2005

I also have something else to add. I have a friend who's an Egyptian doctor and one of the best in the world at what he does, pediatric urology. His hospital in Mansour is a textbook case of a 'paperless office' in that they use computers throughout the facility, PDA's to access patient data and are allowed to purchase and use medical equipment throughout the world whereas here in the U.S. it can only use U.S. equipment. He speaks at medical lectures all over the world to educate other doctors on his techniques and so has the benefit of seeing other hospitals besides his own. He thinks that U.S. hospitals are, although good, nowhere near as good as hospitals in other first world countries (Canada, as an example, where he is now visiting).
posted by mk1gti at 10:49 AM on April 17, 2005

The unique factor about the American health care system is that health insurance is tied to employment. 63% of Americans get health insurance through employment, 24% get insurance through government programs, primarily the elderly through Medicare, and 14% have no health insurance. Only a tiny percentage of Americans buy their own insurance.

The trend to a national health insurance program is becoming more likely as giant corporations such as GM, Ford, United and Boeing realize that they don't want to be in the health insurance business. The conservatives that oppose socialized medicine will eventually lose as their corporate benefactors turn against them.
posted by JackFlash at 11:03 AM on April 17, 2005

According to this international comparison survey (which is a pretty interesting read), Americans don’t have much faith in their primary care system. In 2004, 33% of Americans surveyed thought the system should be rebuilt completely, compared to only 14% of Canadians or 13% of people from the UK.
posted by Staggering Jack at 11:04 AM on April 17, 2005

George_Spiggot -- American big city ERs and the medical care they dispense to the poor only suck in comparison to everything else in America, where the customer is king, and even workers in the DMV have been schooled in customer satisfaction. If you spend a few shifts in the ER, you'll discover that everybody gets processed, patients are justly and fairly triaged, and there waiting room is not filled with the skeletons of people who died waiting for care.
posted by Faze at 11:05 AM on April 17, 2005

Kling's argument might be worth following, if he didn't start right away with a paragraph-full of name-calling.
posted by clevershark at 11:06 AM on April 17, 2005

So, how's the treatment for leukaemia in your local emergency room? How many angioplasty or bypass operations do they do? Does your ER manage AIDS cases, diagnose and treat neurological disorders? To suggest that the ER constututes a reasonable substitute for healthcare not only barfs in the face of economic reality -- what with it not only costing many times more to treat a qualified case once it's got to emergency room conditions, but that identical treatment costs much more to give in emergency room conditions -- but also ignores the fact that the major, bankrupting conditions are not broken legs and gunshot wounds, they're cases that require serious diagnostic attention, can be avoided or reduced by preventative care, and require followup treatment and a relationship between doctor and patient somewhat beyond that between fast-food worker and customer.

Not only do you get none of that in the ER, what you do get costs more, and the recourse suggested here ends up costing all of us both in money and diminished value of swamped emergency services. This is not only far worse than socialized medicine, it's worse in the ways that its opponents particularly deplore, a monstrous hidden subsidy that robs us all.
posted by George_Spiggott at 11:07 AM on April 17, 2005

Here are some more interesting stats from the survey I posted earlier, 27% of Americans surveyed skipped medical tests, treatments, or followup (compared to 2% in the UK, 8% in Canada, 18% in Australia). 16% of Americans went to the ER for a condition that could have been treated by a regular doctor or source of care if available. (compared to 6% in the UK, 18% in Canada, 9% in Australia.)
posted by Staggering Jack at 11:25 AM on April 17, 2005

That first sentence should have read - skipped medical tests, treatments, or follow-up because of costs. Yeargh.
posted by Staggering Jack at 11:27 AM on April 17, 2005

Having experienced, to a greater or lesser degree, the healthcare systems in the U.S., U.K. and France I have to say the French have it pretty good. I put it down to the judicious use of that dreaded "S" word, Socialism, in their policies.

re: Kwanster's links. I didn't realise astro-turf was a useful focus for rebuttal.
posted by gsb at 11:32 AM on April 17, 2005

Regarding your statement that health care related bankruptcy is not fact, it is true: the leading cause of bankruptcy in this country is health care costs.

Hooey.
posted by trharlan at 11:41 AM on April 17, 2005

there is no system. there is only predation.
posted by quonsar at 1:23 PM EST

Hear, hear!

Let's compare Krugman to Kling. NYT column, respected professor. Glassman "Dow 30,000's TicksuckerStation, known paid partisan. Point to Krugman.

Americans should be deeply ashamed of the way we do health care.
posted by nofundy at 11:42 AM on April 17, 2005

In Jan. 2004 I had to go into the ER because of sever abdominal pains, I was there 4 hours given many tests, was finally given a perscrip for Loratab, told they didn't know what was wrong and sent home. The bill came to 6k. Thank god I don't work at WalMart, but have ok insurance. I ended up paying about $500 out of pocket. The pain has gone away, but I still have some affects (that I care not to discuss). But you know, I don't feel like going back for a second whack. I wonder if cost is one of those things that inhibits males for seeking medical treatment?
This non-system sucks. I do not see how anyone can defend it with any amount of compassion in their heart.
posted by edgeways at 11:46 AM on April 17, 2005

I didn't realise astro-turf was a useful focus for rebuttal.

You can attack the content of the article, as others here have done, or you can play the astroturf card. Are you out of ideas?
posted by trharlan at 11:46 AM on April 17, 2005

trharlan
Linking to an article with more 'hooey' is a poor defense. Try something a bit more credible than Volokh's right-wing conservative propaganda.
posted by mk1gti at 11:54 AM on April 17, 2005

This post actually made me finally pay my $5 membership.

Let me tell you about my last visit to the emergency room, in January 2005, the abridged version:

Midnight. Cut and hurt hand real bad. Big cut, too big to fix myself. No insurance, must drive self to hospital. Check in. Dirty look from security guard. Nurse fills out paperwork. It’s clear nobody gives a damn about me. Takes me to cubicle. An hour goes by. An orderly comes in and grabs some stuff out of the cabinet. Another hour goes by. Doctor sees me. Petulant, condescending little hack. Grabs my finger and twists it around. I cringe and beg him to stop. He laughs, smiles and tells me I’ll need some ligament work. Another hour goes by. Big fat ugly x-ray tech takes me to x-ray room. Also couldn’t give a damn about me. Didn’t bother to tell me I could sit down while the film was developing. Thirty minutes later, they finally send a nurse in to cleanse the wound and give me a tetanus shot. Thirty minutes later the doctor gives me 13 stitches. Thirty minutes later a nurse jerry-rigs a cast to keep the finger from bending. Big fat orderly comes in and makes jokes about the process. Five in the morning, nurse comes in and makes me sign papers. Points me to the door. I get lost trying to get out of the place and the janitor had to escort me out. Five hours, $2000.

If I were a dog, they’d have treated me better.

American health, best system in the world? Far from it.
posted by rougy at 11:57 AM on April 17, 2005 [1 favorite has favorites]

you can play the astroturf card

trharlan, that the source is a known paid mouthpiece of the affected industries is not, I grant you, the most compelling argument against it. However, obvious and traceable bias is worth pointing out.

If Kling can base his entire article on repeated, completely unsubstantiated insinuations that Krugman is the head of a cabal that seeks to give the government control of the healthcare , his own -- provable -- biases are fair game.
posted by George_Spiggott at 12:00 PM on April 17, 2005

JackFlash up above alluded to the huge costs being sustained by the GEs etc, but the mid-sized company I work for is having enormous problems too and I can't imagine they're alone.

Six years ago my employer-provided coverage was outstanding - everything covered, free physicals, no referrals required, wide provider net, blah blah. Now we're on our third HMO in 3 years. We have large deductibles, our office and pharma co-pays are leaping up annually, my original doctor and ob-gyn are no longer the network and guys in the office who have wife-and-kids at home are looking at $500 a month in their share of the premiums. The bosses spend a huge amount of time worrying about it.

I really can't complain - I'm healthy so the pressures on me are minimal, and if worst comes to worst my Irish citizenship gets me coverage at home, but I cannot see this system as sustainable at all.
posted by dublinemma at 12:06 PM on April 17, 2005

The unique factor about the American health care system is that health insurance is tied to employment... giant corporations such as GM, Ford, United and Boeing realize that they don't want to be in the health insurance business. The conservatives that oppose socialized medicine will eventually lose as their corporate benefactors turn against them.

To me, the most interesting points in the thread. The current employer-health-care-as-tax-deductible-compensation model is a New Deal Relic-- just screwy, with all sorts of unwanted side-effects, reduced competition, and cost obfuscation. When GM and Ford push for socialized medicine to cover their unfunded liabilities, who will decry the corporate welfare?
posted by trharlan at 12:07 PM on April 17, 2005

Well, Spiggot, no one usually cries when someone links to Kos.
posted by trharlan at 12:10 PM on April 17, 2005

Whassamatta, mk1gti?

Zywicki's piece is a thorough fisking of some extremely poor scholarship that people like you continue to peddle as if it were simple, uncontested fact.

But it's on Volokh, so I have to do better? Enjoy your small-minded dismissal, and pat yourself on the back. I have better things to do than argue with kneejerk ideologues who ignore inconvenient facts.
posted by trharlan at 12:21 PM on April 17, 2005

I can safely say that I've had more experience with the health care system than 99% of the folks here. And the bottom line is that it doesn't work very well. For the amount of money we pay for it, it works astonishingly badly.

There are so many problems I hardly know where to begin. From the outrageous number of mistakes that get made in hospitals to the inefficiencies of health insurance to the almost random decision making process that often decides whether patients are eligible for specific treatments to the idiocy of policy that encourages patients to use emergency rooms as their primary medical outlet, it's all a huge mess.

Yes, there are good things about the U.S. medical system. If you are rich and want to get the most expensive, comprehensive medical testing in the world, you can probably get it. Yes, we have some of the best doctors in the world, especially in the realm of specialists. But that doesn't make up for the weaknesses the majority of Americans deal with when they attempt to get basic, everyday care.
posted by gspira at 12:27 PM on April 17, 2005

George_Spiggot : the major, bankrupting conditions are not broken legs and gunshot wounds, they're cases that require serious diagnostic attention, can be avoided or reduced by preventative care, and require followup treatment and a relationship between doctor and patient somewhat beyond that between fast-food worker and customer.

I think you're oversimplfying the relationship between "major bankrupting conditions" and ER visits. Having one of these conditions myself, I can tell you that with it comes the knowledge that you will end up in an ER (sometimes frequently) due to ineffective medication, the inability to get in touch with your physician, and/or simple emergencies happening related to a pre-existing condition. This leads to referrals back to the physican which leads to (most often very very expensive) testing to try and pinpoint the problem and avoid future ER visits. This has been cyclical in my experience and for people with chronic disease, ER visits are part of ongoing treatment - and certainly the most expensive part of it.

My point is that you can't tease apart "ongoing treatment" and "ER visits" when talking about the US method of healthcare because it's just not possible. Preventative healthcare doesn't prevent breakdowns in the system when medication fails or doctors take vacations. Shit happens.

I know from experience that ER visits are the most expensive form of treatment and when you rack up a few of them in a short period of time, I can certainly see how bankruptcy would occur. One visit in the case of a gunshot wound certainly won't leave you in long-term debt, but the AIDS patients and cancer patients you cite probably visit an ER once a year at least, potentially more frequently. That on TOP of constant doctors visits, tests, and medications will break the bank easily.
posted by grapefruitmoon at 12:54 PM on April 17, 2005

American big city ERs and the medical care they dispense to the poor only suck in comparison to everything else in America, where the customer is king

The "customer" is the person who pays the bills. I'm sure that insurance company representives are treated very well when they make business visits to hospitals.

In Jan. 2004 I had to go into the ER because of sever abdominal pains, I was there 4 hours given many tests, was finally given a perscrip for Loratab, told they didn't know what was wrong and sent home. The bill came to 6k.

In Oct 2004, I went to the ER after three days of abdominal pains (sometimes severe), fever and diarrhea. After the requisite long wait and some prodding by a nurse, I was interviewed by a physician on duty. On of the things he did was to jab me in the approximate area of my appendix. Despite not getting any reaction from me, he decided to order an MRI of my abdominal region to "rule out appendicitis."

I can't help but think that this was done because 1) the fear of being sued for a wrong diagnosis is high and 2) I have very good insurance and this was a profit opportunity.

The next six hours were very educational. I got to experience the dreaded "barium enema" and the joys of the minimally modest hospital gown -- both firsts for me. And while I learned a lot and was treated very well by the ER staff, I'm not sure it was worth the initial $12,000 bill that I received -- an event that could easily have caused another trip to the ER. After the insurance company got their hands on the bill, it dropped to under $9000 -- my share of which was about $2000.

So, the care I received was top-notch -- by some standards, undoubtedly "better" than what I would have gotten in a more socialized system. And yet, I can't help but think that neither my insurance company nor I really got our money's worth. Ultimately, twenty dollars' worth of antibiotics ended up fixing the real problem, which was a Campylobacter infection.
posted by Slothrup at 1:30 PM on April 17, 2005

On another note, does the article ever actually tell you where the best place to get sick is? Canada?

I've been sick in the US and in Iceland and to compare the two systems, sure, the US is a lot more expensive. Especially when it comes to prescription drug coverage. This thread has talked a lot about ERs, but what about prescriptions? There's an expense in which Americans certainly pay more than everybody in ROW (rest of world) and there are far more Americans who take a prescription every day than end up in ERs on a regular basis.

(Also : if we're griping about ERs - everyone's got a horror story, mostly due to the fact that triage is impersonal and doctors and nurses are overworked and understaffed and so of course the "couldn't care less" attitude comes across when dealing with anything less major than a car wreck. I have observed that the only way to receive decent and prompt care is to be brought in on ambulance, although that will rack you up another $800. This I have learned the hard way. Other than that... it helps if you know the doctor. As in, are best pals.)

Back to the prescriptions - here in Iceland where I am not convered by the wonderful socialist system (being that I am a filthy immigrant), I pay $200 USD for a six month supply of my medication. In the US, were I paying retail, the same amount would cover just one month. Further comparison : my birth control shot which is selectively covered by US insurance retails at $120. Here, it is less than $10. I can actually afford to buy my medication retail here even though I don't have insurance, whereas even thinking about doing so the US makes me want to weep and rip out my hair.

Surely, there's a benefit somewhere to our privatized drug system, but it's certainly not in providing affordable drugs for patients. The 10 year waiting period before cheaper generics can be substituted for new drugs is certainly a good indicator of that.

One last comparison between the US and ROW (in this case, Iceland). When I went for emergency care in the US, I was given top of the line drugs and adequate follow-up care. In Iceland... the quality of the emergency care, while I felt more "paid attention to" as a patient - I was a little concerned that corners were being cut as the drug treatment I received was at the absolute bare minimum of helpful. I have epilepsy, and when I enter a US hospital after a prolonged seizure (for me to go to an ER, it must be 5 minutes or more, which for a seizure is damned long), I'm immediately started on valium to ensure that another seizure does not start. In Iceland, I was allowed to have a second 12 minute seizure after the initial 15 minute seizure that brought me in and valium was only administered to me AFTER the second seizure. Say what you will about ignoring patients and having long waiting periods, at least they provide medication.
posted by grapefruitmoon at 1:35 PM on April 17, 2005

hhmm, as that famous agitator Martin Luther King jr used to say, inequality about health care is the most savage kind of inequality.

A Clark County jury unanimously ruled on Wednesday night that Sunrise Hospital was not responsible in the death of a homeless man despite refusing to treat him and forcing him out of the emergency room 10 years ago.
The homeless man, Rodolfo Anguiano, died two and a half hours after he was first admitted to the hospital. He repeatedly asked to be treated for pains but was refused further care by the hospital staff.

be proud of your system, man.

_________

, or you can play the astroturf card.


ah the "astroturf card", like going to a restaurant and, upon finding a turd on one's steak one has the audacity to play the "turd card" and, like, complain. this is priceless, please keep them coming kwantsar.
anyway:

"(TCS) doesn't just act like a lobbying shop. It's actually published by one--the DCI Group, a prominent Washington "public affairs" firm specializing in P.R., lobbying, and so-called "Astroturf" organizing, generally on behalf of corporations, GOP politicians, and the occasional Third-World despot. The two organizations share most of the same owners, some staff, and even the same suite of offices in downtown Washington, a block off K Street. As it happens, many of DCI's clients are also "sponsors" of the site it houses. TCS not only runs the sponsors' banner ads; its contributors aggressively defend those firms' policy positions, on TCS and elsewhere.
James Glassman and TCS have given birth to something quite new in Washington: journo-lobbying. It's an innovation driven primarily by the influence industry. Lobbying firms that once specialized in gaining person-to-person access to key decision-makers have branched out. The new game is to dominate the entire intellectual environment in which officials make policy decisions, which means funding everything from think tanks to issue ads to phony grassroots pressure groups. But the institution that most affects the intellectual atmosphere in Washington, the media, has also proven the hardest for K Street to influence--until now."

famous commie blogger Matt Haughey on TCS:

Last year, when I heard that TechCentralStation was a lobbying group that participated in some shady campaigns disguised as journalism, I didn't pay it much mind, since beyond simple politics, it didn't seem to result in a spate of bad articles there. Well, I guess that time has passed, when I found their concerted effort to discredit Morgan Spurlock's film Supersize Me.
Looks like some whacky conservative outfit even tried to replicate Supersize Me, but with tons of exercise and different choices to somehow show McDonalds was healthy.
update: Oh perfect, TechCentralStation receives funding from McDonalds, among other corporations.

posted by matteo at 2:10 PM on April 17, 2005

The only problem with this "fact" is 1) it's not true and 2) it's not better to wait, in pain and on queue, for treatment if you have the option to walk into any ED and get treated, as is required by federal law.

It is true and the waits if you are on public health care wait times are comparable between the UK and US. I'm having fun with this at the moment as I need a knee surgery. As I've been working in the UK I have no US insurance, if I go back there I either wait 12 months for insurance to kick in for a pre-existing condition or I pay approx $15K. In the UK I wait 3 months under the NHS for free treatment or I can have surgery tomorrow for about $5K. With a top surgeon.

If I need emergency treatment in the UK I could walk into any ER and be treated exact same as the US, except without the bill. I know of one family who received a $55K ER bill after their daughter was in a car accident. That was before the 10 day ICU stay. They had insurance but with a $2K deductible and 20% of the next $10K, plus overage charges they still had an $8K bill. Luckily they had insurance, I know plenty of people who don't.

I work in an industry that runs on contract work and this is a HUGE issue. It effctively bars an enormous number of trained people from entering the workforce as they can't afford the individual premiums. Either that or they take their chances and hope nothing happens.
posted by fshgrl at 2:26 PM on April 17, 2005

on the astroturf stuff, i think you just have to be aware of who's putting out the stuff and try to evaluate the argument from there...

I actually think that alot of this comes back to the biases that we have that resulft from simplifications, that resulft from it being very hard to actually understand how firms markets and societies actually work. Anyways here are some other links looking at the issues

from "lefty" crooked timber blog...
here herehere
posted by stratastar at 2:27 PM on April 17, 2005

I'm kind of sick of seeing people who have health insurance and well paid jobs debate the merits of the US health care "system". It's not a national system it's a consumer product.

Thank you! As someone who's always been on the brink of not having any health care or having no health care at all for 22 years (I'm 22 now), all of you "America has the best system EVAH!!!!" people are really fucking insane. If we have the best system on the planet then does that mean poor and working class people like me don't matter? Does that mean our experiences with the health care "system" are somehow worth less than those fortunate to have been born into the right class and to the right kind of upwardly mobile parents?

Only once in my life did I ever have what I would consider excellent health care, and that was when I took a shitty (but unionized) job at a grocery store which forced me to reduce the number of courses I took to only two or three a semester instead of the usual 4 to 5 (thereby further delaying my graduation which I am to rely on to somehow magically materalize a great job with excellent benefits when I enter the "real world"). You same crazy people who are against socialized healthcare are probably also against the right of workers to unionize, I'm sure, even though it was pretty much the only decent paying, healthcare-providing job available to a non-skilled completely independent 18 year old.

Tomorrow I am scheduled to have surgery on my bladder which I should have had over a year ago (or possibly when I was a child, if I would have recieved the level of healthcare my parents couldn't afford). I spent almost a year visiting third-world-like grimey health clinics where I was consistantly ignored or given (expensive, I'm sure) tests that proved totally unnecessary. Finally after all their half-assed attempts, they broke down and agreed to refer me to the city's general hospital. A month later (no waiting in the American system, huh?), within 20 minutes, they knew exactly what was wrong with me and scheduled me for surgery (another month wait for that).

So, in the "Great American Healthcare System", I had to wait well over a year to get a diagnoisis that only took twenty minutes once I saw a real doctor in a real hospital. It then took over a month to get a surgery that the urologist said I needed "yesterday". Not only did I needlessly suffer for over a year (plus miss many days of work due to illness and daylong clinic visits), but I also must have cost the "system" many many more dollars being inaccurately tested (because they'd rather it was a cheaper illness even though all signs pointed otherwise) than if I were treated with the same respect and dignity that someone with money to throw around with would be.

Luckily, I am intelligent and assertative enough to have navigated Ameirca's "poor people's" healthcare system. Its structured (like most American welfare programs) in way to encourage you to give up and go away (and die, presumably). After everything is said and done, I am still going to owe the city and the hospital more than I know how to pay without cutting out more classes and even further delaying graduation.

Tell me, all you right-wing idiots, how I AM doing better under the current system? I've never heard ONE convincing argument that speaks to me and my experiences and doesn't pull out the old boogeyman of "socialized medicine" and waiting for treatment. In the current system, poor shlubs like me are still waiting and it is only the wealthy who get to skip over us. How is that better for ME?

Sorry for the rambling, all over the place rant. I'm just so fucking sick of right-wing justifications of their greed and contempt for working-class America.
posted by Boydrop at 2:53 PM on April 17, 2005

Although average wages in France and the United States are similar, American doctors are paid much more than their French counterparts.

Is this net or gross? I'm wondering in particular about the cost of malpractice insurance. Does anyone know?
posted by IndigoJones at 3:01 PM on April 17, 2005

Or the cost of medical school loans?
posted by Boydrop at 3:03 PM on April 17, 2005

Doctors don't make that much money now for their level of education. As the spouse of a medical student, we'll be paying huge loans while she makes very little money for several years. She could have looked forward to a much larger salary going to the business school down the river than going to medical school. What percentage of the rising cost of medical care is going to doctors' salaries? Not much.
posted by McBain at 3:14 PM on April 17, 2005

Despite not getting any reaction from me, he decided to order an MRI of my abdominal region to "rule out appendicitis."

It was probably done because it's smart to absolutely rule out appendicitis, as it is life-threatening. I just had an uncle-in-law seriously, for real, and no-shit almost die because the ER didn't bother to ultrasound or otherwise scan him after he reported pain and tenderness in the lower right quadrant, and his appendix burst spewing crap all over his insides.
posted by ROU_Xenophobe at 3:26 PM on April 17, 2005

IndigoJones has hit an important point. Malpractice insurance is a big factor in the cost difference.
Another big factor is the cost of drugs. In countries with national health services, the national health service buys most drugs. It has an enormous purchasing power and therefore can squeeze the best deals out of pharmaceutical companies, much in the same way as Wal-Mart squeezes the best deals out of its suppliers. Furthermore, in most developing countries pharmaceutical companies are actually banned from advertising prescription drugs directly to the public.
Fact is, the main reason why health care is so frigging expensive in the US is because, besides those who actually provide health care, a lot more people (malpractice lawyers, insurance companies, drug advertisers) are making a living out of it. Period.
posted by Skeptic at 3:32 PM on April 17, 2005

ROU: I thought there were simpler and far less expensive ways to diagnose an appendicitis than an MRI. It sounds like ridiculous overkill. Again, fear of malpractice lawsuits seems to be the real motivation there.
posted by Skeptic at 3:36 PM on April 17, 2005

Skeptic : Definitely malpractice suits (and the fear thereof) drive a lot of what doctors do. MRI is certainly the most definitive test to rule out appendicitis, so I can certainly see why a doctor with the means to do so would order one. It's also the most expensive test... funny how that happens.

Malpractice suits aren't just limited to doctors. Nurses get charged all the time as well. My mother is a nurse who works in an OB ward and anytime there's a death of a newborn, every nurse who attended the patient gets named in the suit as well as the doctor. Nurses certainly don't have malpractice insurance, nor do they have salaries large enough to cover endless lawsuits.

Also, EMTs and paramedics are sued left and right. I've gone through EMT certification and fully half of what you're taught is how to document everything that you do so that when, not if, you are sued, your ass is covered. Again, no malpractice insurance and no high salary to boast of.

It's not just doctors. Some people who believe that they've been wronged by the healthcare they receive will sue anyone and everyone they can get.

(Are some of these suits worthy of pursuit? Of course. But certainly not everyone who sues the medical establishment does so because their doctor left a piece of equipment in after surgery. Or didn't read their X-ray. Or whatever.)
posted by grapefruitmoon at 4:21 PM on April 17, 2005

Certainly, malpractice issues are a problem, especially for obstetricians. Juries like to pay off families who have suffered even when no one is at fault, and the fact that insurance companies are the ones doing the direct act of paying makes those outcomes more likely.

Unfortunately, the medical profession, like most professions, does a lousy job of policing itself. A small percentage of doctors are responsible for a large amount of actual malpractice, but it's rare that those doctors get expelled from the profession.
posted by gspira at 8:15 PM on April 17, 2005

Good on you, Boydrop. Its time the voices of the huge number of non- or under-insured USians got a run.
The constant moan from the right is that socialised medicine will result in lower quality of care.
This fails a simple economic test. If we assume state care provides an adequate base level of care, why do these free marketeers think there is no additional care available?
I pay my state medicare levy in Australia, plus an extra $700 per annum (for me, my wife and two kids) for private hospital care should I wish to bypass waiting lists for elective surgey.
If I had no private insurance, I can still pay cash for immediate private care, or wait for 'free at the point of delivery' state care.
This seems to offer a tremendous compromise and in many ways offers true market forces by allowing competition for non-immediate healthcare, but regulating emergency healthcare (where there is really a captive market. How much shopping around can you do unconcious in an ambulance?).
I have yet to see a US free marketeer effectively argue any advantage of a US free market over such a socialised system (which is also available in the UK, I know, and most other 1st world countries, I am lead to believe).
posted by bystander at 8:17 PM on April 17, 2005

It was probably done because it's smart to absolutely rule out appendicitis, as it is life-threatening. I just had an uncle-in-law seriously, for real, and no-shit almost die because the ER didn't bother to ultrasound or otherwise scan him after he reported pain and tenderness in the lower right quadrant, and his appendix burst spewing crap all over his insides.

No question that appendicitis is a serious matter. But the complete lack of tenderness in the appropriate area should have been enough to rule it out. From what I understand, the doctor wouldn't have been able to touch the area, let alone jab it repeatedly.
posted by Slothrup at 9:11 PM on April 17, 2005

Well, my $0.02 is this: I'd much rather get sick in Japan, where I have a limited grasp of the language and am often treated like a second class citizen.

The medical care will be superior to the US, and the cost will be much, much less. In Japan, I took a blow to the head resulting in a trip to the ER for a set of head x-rays and a handful of stitches and antibiotics (and a follow-up visit) ran me about $70USD total.

By contrast, my son got hit in the face with a cardboard box over here, which cut him on the inside of his lower eyelid. My wife told me he was bleeding from his eye, so I said take him to the ER. A 5 minute look from the doctor (who was on the phone with her boyfriend most of the time) and a tube of antibiotics came to over $200. No stitches, no nothing (not that anything more was necessary).
posted by bashos_frog at 6:44 AM on April 18, 2005

I knew Dave Barry and you, sir, are no Dave Barry.

Good catch, and guilty as charged.

I don't pretend to know how to fix the medical "system" in the US - it's too complicated. And from my eye, NOBODY gets out ahead - not doctors, not hospitals, not insurers and definitely not patients. The only people making out in this "free market" system are pharmaceutical companies and a few lawyers and politicians.

But what I do know: In 1993, Hillary Clinton proposed a national medical plan that would have provided insurance to everyone. It was killed because some people feared socialism, and others didn't care to hear from the President's wife. Okay, fine. That's what deliberative bodies are supposed to do.

But what isn't fine is that the Republicans, who control everything, have done absolutely NOTHING to create a compromise, or an alternative solution. They prefer the status quo. They prefer to make it verboten to even mention fixing the problems, short of a rip-off prescription plan for seniors that actually made things worse.

Fuck them.
posted by fungible at 8:44 AM on April 18, 2005

A few points (as a healthcare executive).

Most doctors and nurses do "give a shit" as that's why they got into the industry to start with. There are bad examples in every field, from brain surgeon to rodeo clown.

Doctors do get compensated reasonably well. The doctors at our practice make multiples more than the highest paid executive. Specialists tend to make fantastic amounts of money, often with very high qualities of life. Very few hospital visits or 3 o'clock am phone calls for dermatologists.

Being a doctor is in no way "easy" but arguing it is not well compensated is disingenuous. If anyone knows someone going to medical school, strongly encourage them to become some sort of specialist as opposed to a General Practitioner. In today's market, there is no need for GPs unless you want to be a small town family doctor (and there's nothing wrong with that).

Better yet, tell them to drop out of med school and go to law school. There is the true potential for "wealth".

Malpractice insurance will be the undoing of the U.S. healthcare "product". We have NEVER had a malpractice claim, and the amount we pay for malpractice insurance is frightening, and obscene. This is after very aggressive "shopping around" for coverage.

Commercial health insurance will be the secondary, or backup, cause of the medical industry's eminent collapse. We saw the premiums for the coverage we provide our employees double in 4 years. All that while, the insurance companies are reimbursing us less and less.

I am endlessly amused by insurance companies that are forced to raise premiums continuously due to "climbing medical costs" and yet the insurance companies report record profits on the business page year after year.

Having a 22 year old claims adjustor or case manager with a bachelors or less who has been on the job for 3 months and won't be there in another 8, trying to lecture an MD on when and why he can use a certain diagnostic test or treatment method is absurd on its face and indefensible, as well as intolerable.

Cash discounting is a Good Thing (tm).

ER's should be a last resort for anything that is not a true, actual emergency if you have anything other than stellar healthcare coverage. Copays are often higher in ER's, and if you have a % plan where you are responsible for some part of the bill, your 20% at the ER may be more expensive than your entire visit at an ambulatory care center or similar clinical environment.
posted by Ynoxas at 8:51 AM on April 18, 2005

A few points (as a physician).

If what Mr. Kling means by "cabal" is a growing consensus among people who have intimate familiarity with an issue beyond punditry, I suppose I am a member of this cabal. There is no one in medicine or health policy who is willing to publicly state that the current system is working. There are many ideas of how to improve health care delivery, some are small steps and some are total overhaul. Almost all of these solutions require the government to take some type of active steps and I have to agree that the current government seems to prefer the status quo.

It's too bad that the debate in the popular media so quickly devolves into communism versus capitalism. The countries that seem to do healthcare more cost effectively that the U.S. do have a much greater degree of government involvement. I have never understood the idea that free-market forces apply to health care. In general, physicians don't set the prices for their services and patients don't shop around for the best deal. If you're extemely lucky, you might get to pick among a couple of health plans and you probably don't have the time to figure out how to pick the one that's the best quality and value, assuming these statistics are even available.

Doctors do get compensated reasonably well. The doctors at our practice make multiples more than the highest paid executive.

Of course I have to take issue with this. I went straight through college, med school, and residency and started making my salary at age 32 and at that point I had racked up a quarter million in debt (for four years of med school alone). If I had started out at age 18 at McDonald's and put the same amount of effort into my job as I did into my training I would be better off today than I am now. My story's not at all unique.

If anyone knows someone going to medical school, strongly encourage them to become some sort of specialist as opposed to a General Practitioner. In today's market, there is no need for GPs unless you want to be a small town family doctor (and there's nothing wrong with that).

Are you kidding me? Are you really serious about this statement? Half the problem with the system is that most people are getting their primary care from specialists. By the way, a GP is someone who did one year of internship 30 years ago. Nowadays, all primary care doctors do at least three years post graduate training, much of which is focused on evidence-based, cost-effective delivery of outpatient clinical medicine.

Malpractice insurance will be the undoing of the U.S. healthcare "product".

While the rise in malpractice insurance of the last three years is pretty shocking and makes great headlines, the crisis in the larger system is much greater and has been brewing for over 20 years. In terms of my practice's long term viability, I am much less concerned about malpractice than my patients' access to care.

I am endlessly amused by insurance companies that are forced to raise premiums continuously due to "climbing medical costs" and yet the insurance companies report record profits on the business page year after year.

On this point, my friend, you and I are in total agreement. :)
posted by Slarty Bartfast at 6:12 PM on April 18, 2005

Slarty:

I have never understood the idea that free-market forces apply to health care. In general, physicians don't set the prices for their services and patients don't shop around for the best deal.

Amen. Though some of that is changing, at least in the ambulatory market. Cash discounting seems to be a positive change, although that is still a badly inadequate solution.

My favorite phrase, that I'm sure I stole from somewhere, is that healthcare is too important to be left to the free market. But when I say that, everyone (including most of my physicians) laugh at me and call me a commie.

I am perfectly serious about the specialist issue. Note I am discussing this from the vantage point of the individual provider, not the market as a whole. I do believe it would be in the provider's best SELF INTEREST to be a specialist, as they make greater salaries and often with less demands on their time, and smaller impact to their personal lives. This is of course not equally true across all specialties, but I think you know what I am getting at.

But, I'm not convinced the market needs more GPs. There doesn't seem to be any shortage that I can see, especially if you consider foreign-degreed providers. Plus, the increasing role of mid-levels again reduces the overall need for GPs. I want to take special note that I am *NOT* saying GPs are not good providers. That is absurd. But if someone is in med school right now, the path of the specialist definitely is brighter than the path of the GP, surely you will concede that.

I take issue with your McDonald's statement, because you and I both know it isn't true. Assuming you are a fairly compensated GP, and not in a depressed rural community, you will make in less than 2 years more than you would have made working 14 years at McDonald's. Then, that ignores your future earnings, which year after year catapult you into the stratosphere of earnings as compared to a McDonald's worker. Your level of debt is very high, but only compared to a McDonald's worker. At your income level, your debt becomes proportional.

So yes, from ages 18 to 32, those 14 years, you were scrimping I am absolutely sure. But, the next 33 years, your professional and personal life will in no way mirror that of a McDonald's employee.

Note I am not saying doctors are over-compensated. But virtually all doctors ARE fairly compensated.

This assumes you are not engaged in some charitable cause or military servitude. Of course, if you were indentured to the military, you wouldn't have your debt load either.

If you are not earning more than a McDonald's assistant manager, then send me your CV, we could use you. :-)
posted by Ynoxas at 7:53 AM on April 19, 2005