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May 04, 2007

A Quick Note on Waiting Times

There are some arguments over comparisons of Canadian and US waiting times flitting through the blogosphere, which reminds me of a point I've been meaning to make for awhile: You can't compare the upper end of US waiting times to the upper-end of any other country, because those with reduced access to the health system forego care, which doesn't happen in significant numbers elsewhere. So while the Right disingenuously trumpets the few Americans reporting severely long waits, they don't mention that the group who would populate that category are locked out of care entirely.

Here's how the dodge works: If you look at waiting times, you'll see that relatively few Americans wait more than four months for surgery, which helps folks claim that America doesn't ration care, and makes our system look pretty good on the waiting times metric. Here's what they don't tell you: When you look at who foregoes care, the international comparisons reverse themselves. About 23% of Americans report that they didn't receive care, or get a test due to cost. In Canada, that number is 5.5%.

Worse, the American number is understated, as in order to know you need a surgery or further care, you need to go for an evaluatory visit, and as it happens, many Americans -- including 36 percent below average income -- aren't even seeking that. And it's this group -- which is largely low-income, and I'd guess, largely urban -- who would, in another country, be experiencing terrific wait times. Here, they never get care at all. The studies misleadingly write them out of the waiting statistics, making it look like America has low wait times when the relevant population is simply never getting care at all.

May 4, 2007 in Health of Nations | Permalink

Comments

Um ... shouldn't someone who forgos care be treated as if they have an infinite waiting time for care? And then, to avoid the undue influence of extreme outliers (which infinite waiting times would be), you look at the median waiting time? Sounds like the way to compare waiting time data fairly, to me at least anyway ...

Posted by: DAS, de facto Statistician | May 4, 2007 3:36:42 PM

This reminds me of how we don't count people who have given up looking or a job as "unemployed." They just cease to exist.

Posted by: Maggie Mahar | May 4, 2007 4:13:41 PM

Just to show how good it gets for someone highly insured: My primary care provider recommended a consultation for me with a colleague in the digestive disorders section at Oregon Health & Science Univ. in Portland. A week later I had the visit (almost an hour). The gastroenterologist in turn, recommended some blood tests and a CT scan. They were both completed within two hours, even though no emergency existed.

I'm (almost) embarrassed when medical care for me is this good, when I think that without the double insurance (medicare and secondary provider from former employer), I wouldn't get past the appointment desk.

I'm becoming convinced that there too many important details - like in Ezra's post - that only a group of policy and practice experts could ever agree on the facts, and then only if this was not a partisan issue. The facts keep getting in the way of the ideologies, so the facts get buried or never unearthed.

The more I think of this, John Edwards plan to erect a parallel national plan with open enrollment, leaving the existing health insurance structure in place for those who want to maintain that, is probably the only way to get to a better future - incrementally, if the national plan proves to be better against the private alternatives.

Posted by: JimPortlandOR | May 4, 2007 4:34:43 PM

Every good is rationed, whether you use a market mechanism or a waiting list. In the United States, we ration products through prices; in the Soviety Union, they ration goods with 2 hour lines and empty shelves.

The great advantage of the market mechanism, though, is that price signals communicate to producers the dynamic needs of consumers. If people suddenly start buying trunkloads of coffe, the price rises, sellers notice the opportunity for a profit, and start selling coffee until the price goes back down.

I do agree the way we pay for health care is broken, and the system at present offers very unequal access. But where I strongly disagree with Ezra is how to actually go about fixing this. Some of the universal coverage proposals put forwad by Democrats don't build upon this market mechanism to best serve consumers. The better approach, in my opinion, is a plan that involves vouchers, HSAs, and high deductible insurance.

Posted by: Jason | May 4, 2007 4:35:19 PM

The "waiting times" dodge is just as dishonest as the "we don't ration" lie. Of course the US rations healthcare.

We just do it by ability to pay. Can't pay? You don't get as much healthcare (either in quality or quantity) as someone who can (if you get any at all).

It's just that the pro-corporate insurance lobby doesn't like to call that "rationing". What the anti-single-payer crowd is really worried about, when it comes down to it, is one or both of the following: (1) THEY might have to wait for healthcare, or (2) an industry that makes money by denying people care (the health insurance industry) might end. I have little sympathy for either position.

Posted by: paperwight | May 4, 2007 4:40:48 PM

The great advantage of the market mechanism, though, is that price signals communicate to producers the dynamic needs of consumers. If people suddenly start buying trunkloads of coffe, the price rises, sellers notice the opportunity for a profit, and start selling coffee until the price goes back down.

Yeah. Markets. Awesome for commodities. Not so good with complex products for which there is an inelastic demand and massive market failures in which information asymmetries are essentially insurmountable. Econ 101 Free market fundies have never seen a market failure -- failed markets just operate at a suboptimal level because of gummint interference.

Posted by: paperwight | May 4, 2007 4:43:49 PM

Jason,

Soviet Union????

What decade do you think this is?

Posted by: gonzoknife | May 4, 2007 4:45:33 PM

What decade do you think this is?

It doesn't matter, because WE'RE TALKING ABOUT SOCIALISM! SOCIALISM! AND THE SAPPING OF OUR PRECIOUS BODILY FLUIDS! THE UNION OF SOVIET SOCIALIST REPUBLICS IS PERTINENT! PERTINENT!

Posted by: paperwight | May 4, 2007 4:47:29 PM

Econ 101 Free market fundies have never seen a market failure -- failed markets just operate at a suboptimal level because of gummint interference.

Just like anti-market fundies have never seen a functioning market, eh? Goes both ways.

Posted by: Jason | May 4, 2007 5:06:41 PM

Jason: Just like anti-market fundies have never seen a functioning market, eh? Goes both ways.

Paperwight: Yeah. Markets. Awesome for commodities.

Care to try again?

Posted by: paperwight | May 4, 2007 5:13:27 PM

Care to try again?

Health care is still a commodity no matter how "complex" it is, and to ignore that can have serious consequences. There is only a finite amount of health care resources, and whichever way we distribute them will come with tradeoffs.

I don't ignore that market failures occur, but I also recognize that government intervention to "fix" the market almost always guarantees a market failure.

Posted by: Jason | May 4, 2007 5:30:04 PM

I don't ignore that market failures occur, but I also recognize that government intervention to "fix" the market almost always guarantees a market failure.

Which is why we have the only western nation with a functioning health care system, of course. Remember all those european countries where they tried to intervene and completely destroyed the health care system? Oh wait? You don't?

Posted by: ryan | May 4, 2007 5:40:49 PM

So, TVA, the Bonneville Power Administration, VA Hospitals, Medicare, The US Marines, are guaranteed market failures, huh? Does the local fire and police departments not being in competition mean they are market failures too? How about the state highway departments that plan and build roads? Should we have competitive highway departments building roads parallel to each other?

Jason, please, there are adults here. What passes for gospel in the Young Republicans meetups won't pass scrutiny here.

Exactly what part of healthcare is a commodity? The MRI scanners? The needles? The knowledge of specialists? Lab analysis? What's the future's price of an Emer. Room resusitation for heart attack in Podunk? Silly guy.....

Posted by: JimPortlandOR | May 4, 2007 5:46:18 PM

You guess that the group who don't seek evaluation visits are largely urban. I wonder if there aren't a lot of rural folks in that number too, given the dearth of doctors and hospitals in small towns. Especially in areas like the west, where the percentage of population is actually more urban than in more populace states, so the small towns are smaller and further apart. It takes serious time out of your life to drive 50 or 100 miles to get an evaluation (not to mention serious cash these days with the price of gasoline).

Posted by: Lukeness | May 4, 2007 6:00:20 PM

since healthcare is a commodity Jason I think you need to do the market a favor and start the trend of giving up your unncessary care. By the way- I find it incredibly frustrating read comments like "I know you are, but what am I" in analysis like calling people anti market fundies just because they question your adherence to a system that doesn't work without actually you know providing us with something that actually would work. How would you make it work? Saying relying on the market is vitually meaningless- because you are a fundamentalist about it- meaning you don't require proof of whether it works or not. The difference here is that regardless of what system is in place no one can claim that Ezra and others are not requiring proof.

Posted by: akaison | May 4, 2007 6:07:33 PM

Which is why we have the only western nation with a functioning health care system, of course. Remember all those european countries where they tried to intervene and completely destroyed the health care system? Oh wait? You don't?

There are two functions a market performs: 1) they distribute resources efficiently, and 2) they send the signals to producers to better satisfy consumer needs in the quest for a profit, a la the coffee example. A government can do #1 so so, but they almost completely fail at #2.

Posted by: Jason | May 4, 2007 6:21:57 PM

I find it incredibly frustrating read comments like "I know you are, but what am I" in analysis like calling people anti market fundies

Actually, I was called a fundie first.

just because they question your adherence to a system that doesn't work without actually you know providing us with something that actually would work.

What would work? Health care vouchers, HSAs, high deductible private insurance, and government-provided high risk pools. Oh and eliminate the tax loophole that subsidizes businesses who provide insurance.

Posted by: Jason | May 4, 2007 6:26:15 PM

Aarrrgh! Yet again, Ezra is playing games with the numbers. A few rather obvious problems with his analysis:

1. The figures for "Did not get medical care due to cost" vary by a factor of more than five among the nations that have "universal health care" or "universal insurance." That suggests that the primary cause of cost-related disparities in access is something other than the presence or absence of "universal health care."

2. The figures do not provide any indication of the importance of the medical care to which access was a problem. Forgoing a visit to an oncologist for cancer treatment is rather more serious than forgoing a visit to a primary care physician for a cold.

3. Since the figures are based on the "citizens' view," they mostly reflect access problems due to out-of-pocket expenses to the consumer at the point of delivery. They do not provide any indication of cost-related restrictions on access imposed by the health care provider or administrator, which are largely invisible at the point of delivery.

Posted by: JasonR | May 4, 2007 6:29:50 PM

"So, TVA, the Bonneville Power Administration, VA Hospitals, Medicare, The US Marines, are guaranteed market failures, huh?"

Yes, those are things the market doesn't allocate for. They also come with lots of problems too. Utilities, for example, correct for market failures, but they also suffer from a lack of competition and the need for large government bureaucracies to oversee them. Which is why we try and limit what services government does in favor of the free market.

Posted by: Jason | May 4, 2007 6:33:56 PM

So, TVA, the Bonneville Power Administration, VA Hospitals, Medicare, The US Marines, are guaranteed market failures, huh? Does the local fire and police departments not being in competition mean they are market failures too? How about the state highway departments that plan and build roads? Should we have competitive highway departments building roads parallel to each other?

It is generally appropriate for the government to be the sole or primary funder of public goods like roads, schools, and police departments. It is not generally appropriate for the government to be the sole or primary funder of private goods like housing, food, clothing and employment. Now explain to me why health care belongs in the first category rather than the second.

Posted by: JasonR | May 4, 2007 6:42:06 PM

"What would work? Health care vouchers, HSAs, high deductible private insurance, and government-provided high risk pools. Oh and eliminate the tax loophole that subsidizes businesses who provide insurance."

red herrings which wouldn't address the issue of quality healthcare at a reasonable cost.

Posted by: akaison | May 4, 2007 6:51:25 PM

red herrings which wouldn't address the issue of quality healthcare at a reasonable cost.

Oh yeah? And "universal health care" isn't?

There are 3 things we demand from a perfect health care system: top-notch health care, affordable, and insulation from the costs. In reality, those 3 properties are a trilemma, meaning you can only choose two at the cost of the third. Socialized medicine is affordable and insulates you from the cost, but doesn't offer top-notch health care. US health care is top-notch and insulates us from the cost, but it is not affordable. The most desirable system, in my opinion, is the third option: top-notch and affordable. Which means we can no longer shield consumers from the cost of health care. That is what HSAs + high deductible insurance are designed to accomplish.

Posted by: Jason | May 4, 2007 7:04:44 PM

Jason
What, you didn't believe Jim from Portland when he said you couldn't hijack the thread with tripe ?
Michael Moore set as the premise of his expose a comparison of taking U.S. Vets to Cuba. Let's ignore Walter Reed momentarily ( something that has been done for years while privatizing manitenance destroyed VA facilities ): HSAs + high deductible insurance are only a theoretical model. The actual facts are "insurers" who 1) won't or 2) duck out on technicalities whenever possible.
We all know there is so much money spent supporting "accounting infrastructure" ( without even worrying about markups every time you insert another layer of business into the delivery model : I can get it for you wholesale ! joke ) without factoring in deadbeat insurers because billing hundreds of companies not even directly involved is such a kludge !
Don't leave out court processing costs for disputes : they are still a subsidy to the system.

Posted by: opit | May 4, 2007 7:50:56 PM

Jason,
How exactly do high-deductible plans deal with the 80-20 problem, where the bulk of the costs come from a small number of very expensive patients?

Posted by: Paul | May 4, 2007 8:10:59 PM

We all know there is so much money spent supporting "accounting infrastructure" ( without even worrying about markups every time you insert another layer of business into the delivery model

Sure, cell phone service would also be cheaper if we designated one company do it all. They wouldn't have to waste their money on marketing and advertising, and thus could charge cheaper rates.

Problem is, with no competition, there is little incentive for a company to respond to consumer needs -- lower prices, better products, better customer service. Your alternative, government-run single payer, is nothing more than a de facto monopoly.

So for all the overhead we pay for in the short term, giving consumers choice would actually benefit us more than everything we save through an efficient monopoly.

Posted by: Jason | May 4, 2007 8:16:05 PM

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