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May 02, 2006

I Wonk Because I Care

By Ezra

This is rather weak stuff from CATO's Michael Cannon on the feasibility of universal health care.  Responding to evidence that Canada only has waiting times for elective procedures and France and Germany don't have waiting times at all, Cannon says that 1) waiting times in Canada can still be harmful to mortality; 2) if asked, French and German citizens are unhappy about waiting periods for care; 3) there's some evidence for improved outcomes on very specific diseases in America.

Well, first, he dodged the actual issue.  Ponnuru had written that universal coverage was an impossible goal.  That was flatly untrue, given the accepted definitions of the words "universal" and "coverage."  What Cannon is arguing here is that there are distasteful affects from universal coverage, which are different, though also important, issues.  So, quickly and in order, I grant his point on Canada, though if he thinks it problematic that Canadians have to wait for elective treatment and those periods are occasionally harmful, he must be truly distressed that Americans often simply can't afford necessary treatment and they routinely die.  As for #2, he's using polling data that looks loaded to me.  I have excellent health insurance but am dissatisfied with waiting times.  Why?  Because I don't want to wait at all, ever.  My guess is Germans and French folk feel similarly.  But the question should be how long they wait, not how they feel about it.   And there, Jon Cohn's data lands a clean left hook for the win.  As for Cannon's last point, I've looked over the data on this.  Indeed, I spoke to Gerard Anderson, who conducted the study.  And what it shows is interesting, and I'm going to spend some time talking about it.  Follow below the fold if you feel like some wonkery.

"For prostate cancer," Cannon writes, "you are twice as likely to die of it in Germany as in the U.S. (44 percent vs. 19 percent)...if that’s the case, the appeal of “universal” coverage fades."  I'd noticed him use this statistic before, and I couldn't find it anywhere.  So I asked him (or his assistant, I can't remember) where it came from.  The work of Gerard Anderson, apparently.  So I called Dr. Anderson, who was certain he'd never found any such stat.  It sounded, he said, "ridiculous."  So I went back to Cannon and finally got the original data.  And now it gets complicated.

Anderson's data did indicate that, but he didn't realize it.  The reason is that the finding is a bit more complicated.  Here's the relevant graph:

Prostatecancermortality

The question here is whether all cancers are created equal.  Why does Germany have less than half our prostate cancer incidence?  And does it mean that their cancers are more serious, less curable cases?  It's unclear.  But the bottom line is that you're no more likely to die of prostate cancer in Germany than the US, and you're also less likely to die of other things.  Here's the part of the data Cannon leaves out when comparing the health systems:

Yearslifelost

I'd think our system is looking a bit worse now.  Meanwhile, the question that Cannon, and others of his ideological ilk, need to answer is whether they think the marginal benefits of our system are worth the marginal cost.  We spend around twice what any other country does per capita, and we see very little, if any gain, from the added expense.  Indeed, there's an interesting thought experiment as to how much better their outcomes would be if they pumped up their per capita spending to match ours.  Meanwhile, they cover all of their citizens (the paper Cannon is using defines all the other countries as having, yes, "universal coverage," that state of affairs Ponnuru thinks doesn't exist), while we have a population of 46 million uninsured, and another 15 or so million underinsured.  20,000 Americans die every year because they lack health insurance, and many more perish because they forego care that turns out to be necessary.  That's the sort of quality we're paying for, and I'm not sure Cannon's slightly confusing prostate stats really balance out the ledger.

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Comments

It must be hell working (like Cannon) for a think tank where the preferred policy position is predetermined, and writers have to find, and often misrepresent, data to support their thesis, or ignore contrary evidence - with the penalty of getting thrown off the train if they don't produce to the thinktank's policy line.

The Japanese sure do seem to have this health thing mastered. Is that because their government has been and is putting libertarian principles into action?

One wonders if CATO has health insurance for their employeees, or do they all commit to health savings accounts as the proof of their fidelity to their cause?

Posted by: JimPortlandOR | May 2, 2006 6:13:30 PM

Isn't there an incidence/prevalence bamboozle going on in the first chart? 63 incidences of prostate cancer per 100,000 men per year means 63 new diagnoses. 28 deaths per 100,000 men means 28 deaths regardless of the original year of diagnosis. So in 1997, 28 men per 100k died of prostate cancer, and 63 people per 100k were diagnosed with prostate cancer for the first time. 28/63 = 44%. The math checks out, but it means nothing. I'd want to know the prevalence of prostate cancer per 100,000 men before telling whether the US death rate is comparable, acceptable, or whatever, relative to the german death rate. As of now, I have data that was calculated on the "half of all couples get divorced" scale -- that is, a steaming pile.

Shorter diddy: Cannon was wrong about Anderson's data, and you can prove it, and I just did.

Posted by: diddy | May 2, 2006 6:31:38 PM

Way to do the research, Ezra!

Could you explain to me how these "potential years of life lost" calculations are done? I've been curious what that means.

Posted by: Neil the Ethical Werewolf | May 2, 2006 8:51:40 PM

I suspect different diagnostic criteria. My understanding is that the most prevalent form of prostate malignancy is usually so slow-growing that victims typically die of something else. But for some, that cancer becomes aggressive, metastasizes, and kills. It thus seems entirely possible that a significant number of patients diagnosed as cancerous in the US would not be in Germany.

Posted by: modus potus | May 2, 2006 9:37:12 PM

Modus potus' instincts sound right to me, especially given the back and forth I've heard on what various PSA results or biopsy results mean.

Another thing it might be is an effect of the reimbursement system--some diseases are sought for and found in part becuase they're very financially rewarding to treat. If we reimburse prostate care well and the Germans reimburse it poorly, that could help explain this stat.

But wow, citing this stat like it means something is either inexcusable ignorance or a deliberate lie.

Posted by: theorajones | May 2, 2006 10:38:24 PM

If the metric can be measured objectively, why the hell look for subjective measures? Are we supposed to take seriously the danger that lowering actual wait times might make us less happy about wait times? Is Cannon suggesting that there's some subtle measure of goodness which the actual numbers on wait times aren't catching?

Posted by: pantomimeHorse | May 3, 2006 12:34:02 AM

Ezra,

Please provide the source discussion for the 2nd chart. "all causes" could, without clarification, be referring to much more than stuff impacted directly by "health systems".

Posted by: Steve | May 3, 2006 1:09:23 AM

I must say, the potential years of life lost calculations seem, if anything, low to me. The difference between Japan and the U.S. is 2401 years, or 0.02401 years of life per capita. That comes out to a little more than a week per person. The disparity between U.S. and Japanese life expectancies at birth, on the other hand, implies that American males lose about three years on their Japanese counterparts, and American females lose about four. Is less than a percentile of this accounted for by healthcare differences? I must be misreading the data here. Is it years of life lost every year by a cohort of 100,000, so that by 40 years, they've lost a year or something?

Posted by: Julian Elson | May 3, 2006 2:31:18 AM

I know it's ancedotal evidence, but having moved to Germany in the last two years I can say without reservation that their health care system is excellent.

The doctors or facilities are not qualitatively different, the waiting times are about the same for both the general and specialized care that I've had, my monthly costs are less, and getting things paid for has been totally hassel-free (that last being the kicker -- my experience back home in the US with various insurance companies was less than ideal).

The only thing I really don't like about German health care is that you can't buy medicine (anything harder than vitamins) in the supermarket -- have to go to a drug store for that.

Posted by: moonbiter | May 3, 2006 4:27:30 AM

"I have excellent health insurance but am dissatisfied with waiting times. Why? Because I don't want to wait at all, ever. My guess is Germans and French folk feel similarly."

Correct! As a german citizen, my personal experience is that people will complain if they have to wait three weeks for a surgery that isn't life threatening, like, say, an ingrown toe-nail. Instead of focussing on polls how people feel about the access to surgery, It would be much more honest (and interesting) to compare statistics about the average time people have to wait for it. And he data should differentiate between life-threatening and less serious conditions.

My guess is that this would show that most western countries are not so far apart in the treatment of insured patients. Self paying people may have the advantage of a faster service, ok, but not very much people can really afford to pay for, say, a heart transplant out of their pocket...

Posted by: Gray | May 3, 2006 8:04:25 AM

Via google, I've checked some german sources about the differences in prostate cancer incidences. It looks like the US uses a method called PSA-screening for diagnosing prostrate cancer. This has led to a huge boost in numbers of possible cancer cases. My guess is that this method produces some false positives, too. Also it has to be taken into account that the average age for patients diagnosed with this is 72 years here in Germany. This is only slightly below the average lifespan for males. The methods of treatment are very advanced in all western countries, resulting in a high chances of containg the tumor even in advanced cases. The chances for surving five years are at 74-80%.

Also it is a fact is that the risk for prostrate cancers depends on genetical, cultural and social factors. In Asia, men are less likely to get it, but the risk for Afro-americans is twice as high as that for caucasian white males. Studies hint that the risk for a male in one country may be seventy times that of the average man living in another part of the world. And scientist at the State University of New York even conclude that stress at the job, with the family or in the surrounding may boost the risk by several hundred percent!

So, this is a very complex issue. And there are huge differencies between different countries. Imho it's impossible to draw any conclusions from a simple graph like the one that cannon is relying on for his dishonest statement.

Posted by: Gray | May 3, 2006 8:43:12 AM

Why are the numbers for Japan in the first graph so low? Thats an amazing difference.

Posted by: Adrock | May 3, 2006 12:27:10 PM

Geez, do you people really ever READ Cato research? You make it seem like Mike Cannon advocates FOR the U.S. status quo, whereas he and his ilk (I'm one of them) advocate just as much change in favor of free markets as the left does in favor of government monopoly. CATO argues that the U.S. health care system KILLS Americans. (See Chris Conover's paper.)

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