Ezra Klein: Rudy and "Socialized Medicine"

October 29, 2007

Rudy and "Socialized Medicine"

I used to believe that one of Bush's primary problems was that he was governor in a state with an absurdly weak governorship. In Texas, the executive is only the fifth most powerful position, and so Bush's disengagement with public policy made sense. He'd never needed to be engaged. I hoped Giuliani would actually be better, as his time in New York required real substantive involvement with policy analysis. And yet it's the same old crap. Here's Rudy's new radio ad on health care:

Rudy's wandering around with the old prostate care canard. It's -- no pun intended -- crap. England and America have vritually the same mortality rates from prostate cancer. In England (as of 1997), 28 males of every 100,000 died from prostate cancer. In America, then number was 26. The difference comes in "incidence" -- there are many more diagnoses of prostate cancer in America, as we have an aggressive screening process:

Problem is, most of those cancers simply aren't deadly, or even necessarily damaging. They're slow-moving and benign. It's like saying we have a lower death rate from car crashes because we record more near-misses in the statistics. We may indeed have a slight advantage of prostate treatment, but it's not what Guliani is suggesting it is.

Not only are Giuliani's numbers wrong, but the whole metric is off. Prostate cancer isn't the only illness we treat. If what you're interested in is years of life lost due to the health care system, well, we have data on that too. This is from the same source as the prostate cancer stats (which are, I'm pretty sure, the ones Giuliani is using, as they're the ones Cato, who started this argument, uses):

America, you'll notice, doesn't do so well. And to make the old point one more time, we're actually having an argument over which system is better, even as Americans pay more than twice as much for care as the British. At that cost differential, there should be no debate. That there's any dispute at all is evidence that we're doing something terribly wrong. But don't worry. Giuliani is proposing a tax deduction...

Assignment Desk: Wouldn't it be interesting to find out if the gold-standard care Giuliani got during his prostate cancer came while he was on government-provided health insurance? He was mayor at the time, suggesting his care was coming through the city, which would suggest it was through the state insurance pool, which works very much like FEHBP -- which is what the Democrats are proposing to expand to all Americans, and what Giuliani is calling deadly, socialized medicine.

October 29, 2007 in Consumer-Directed Health Care, Health of Nations | Permalink

Comments

Facts for you:
1) The NHS is pretty bad, and a lot of people don't use it
2) The private sector is in large part composed of the NHS trading privately
3) No-one goes bankrupt here because of illness here
4) The NHS is good value
5) Please talk about the French medical system more.

Posted by: Marcin Tustin | Oct 29, 2007 3:40:07 PM

Ezra,

You are confusing "incidence" (the rate at which the disease occurs in the population) with "diagnosis" (the rate at which the disease is detected in the population). If the incidence of prostate cancer is higher in the U.S. than in Britain, then equal mortality rates from prostate cancer implies superior rates of detection and/or successful treatment in the U.S.

And your second chart is not data on "years of life lost due to the health care system," it's data on years of life lost for all causes. This is obviously determined by everything from homicide and suicide rates, to the rate of smoking, to the rate of fatal motor vehicle crashes. It doesn't tell you anything whatsover about differences in years of life lost due to differences in the health care systems.

Posted by: JasonR | Oct 29, 2007 3:42:07 PM

What are the other four? Lt Gov, sure, and I guess Speaker, and probably Senate majority leader. Who is the fourth? Senate minority leader? Agricultural Commissioner? Attorney General?

Posted by: Nicholas Beaudrot | Oct 29, 2007 3:42:26 PM

No-one goes bankrupt here because of illness here

Wow. So if you become seriously ill or disabled in Britain (what I assume you mean by "here") and can no longer work, the government will pay off your mortgage, your car, your credit cards, your student loans and whatever other debts and financial obligations you may have, will it?

Posted by: JasonR | Oct 29, 2007 3:46:49 PM

What are the potential years of life lost because we are the fattest and laziest society to ever exist?

Posted by: Dingo | Oct 29, 2007 3:48:16 PM

Jason: Incidence is only recorded upon detection. We have higher incidence because we have more aggressive screening. As I understand it, there's not a whole ton of debate on this question.

As for the years of Life Lost metric, the study defines it as "Potential years of life lost measures the years of life lost prior to age 70 due to causes considered preventable given appropriate medical intervention. As a result, deaths during childhood can have a major influence on potentially years of life lost." So it's only causes that the health system should be preventing. What you're seeing aren't homicides but a lot of infant mortality, which America is absurdly bad at addressing among minority populations.

Posted by: Ezra | Oct 29, 2007 3:52:06 PM

What's up with New Zealand? France and Germany, I get (large [presumably undertreated] minority populations, especially in France). But New Zealand? Is it skin cancer (the Kiwis I know live in constant fear of it)?

Posted by: Joe | Oct 29, 2007 4:09:44 PM

Ezra,

Jason: Incidence is only recorded upon detection.

But that's not "incidence." Incidence is the rate at which the disease occurs in the population, not the rate at which it is detected.

We have higher incidence because we have more aggressive screening.

No, we have a higher rate of diagnosis. That is probably in part because of more aggressive screening, but it may also be in part because prostate cancer occurs more frequently in American men than in British men. Unless you have evidence that prostate cancer occurs at the same rate in both countries, you cannot draw the conclusion that the more aggressive screening in the U.S. is of no value on the grounds that the prostate cancer mortality rates are the same.

Deaths from homicide, suicide, car accidents, smoking, poor diet, etc., certainly include deaths that are "preventable given appropriate medical intervention." If the U.S. health care system is twice as good at preventing deaths from, say, attempted homicide as the British health care system, but the rate of attempted homicide is three times higher in the U.S. than in Britain, then the rate of homicide deaths in the U.S. will be higher even though the U.S. health care system is better at preventing them. Unless you control for differences in the incidence of the different causes of death between the two countries, you can't draw any meaningful conclusions about differences in the effectiveness of their health care systems at preventing those deaths.

Posted by: JasonR | Oct 29, 2007 4:11:38 PM

Why is it that the horror stories that the right prefers to trot out are usually for procedures (joint replacements) or ailments (prostate cancer) that are mostly covered by the government (i.e., Medicare) anyway? Sounds to me like the stats aren't nearly as favorable to their cause when it's something that primarily affects those under 65... like, say, maternity care.

Posted by: latts | Oct 29, 2007 4:17:46 PM

"Wow. So if you become seriously ill or disabled in Britain (what I assume you mean by "here") and can no longer work, the government will pay off your mortgage, your car, your credit cards, your student loans and whatever other debts and financial obligations you may have, will it?"

Wow. Way to be obtuse, JasonR! In case you're not being obtuse and are, in fact, just slow, the difference is that the providers of the financial instruments you listed all offer insurance to protect you (and them) against the event of your long-term disability.

So you might go bankrupt because the insurance products provided by the market to cover your financial obligations are inadequate or because you didn't purchase such products.

There is, however, no need to protect yourself against the specific risk of becoming ill since being ill does not create a new financial obligation. Hence, you can't go bankrupt from being ill per se.

Posted by: Andrew | Oct 29, 2007 4:20:49 PM

Rudy is just lying. You know nothing more after these guys speak than you knew before.

Posted by: floccina | Oct 29, 2007 4:20:59 PM

The Japan numbers make me think race has an effect and so all the numbers need adjusting.

Posted by: Floccina | Oct 29, 2007 4:24:36 PM

the difference is that the providers of the financial instruments you listed all offer insurance to protect you (and them) against the event of your long-term disability.

Huh? First, that's not a difference (insurance against these losses is also available in the U.S.). But even if it were a difference, the mere availability of such insurance obviously doesn't mean that people will buy it.

So you might go bankrupt because the insurance products provided by the market to cover your financial obligations are inadequate or because you didn't purchase such products.

Yes, indeed. So Marcin's claim that "No-one goes bankrupt here because of illness" is false, isn't it?

There is, however, no need to protect yourself against the specific risk of becoming ill since being ill does not create a new financial obligation.

Nonsense. There is obviously a risk if you have existing financial obligations that you will no longer be able to meet if you become ill and can no longer work. And illness can certainly impose new financial obligations that will not be covered, or will only partly be covered, by the health care system.

Posted by: JasonR | Oct 29, 2007 4:34:41 PM

We may indeed have a slight advantage of prostate treatment, but it's not what Guliani is suggesting it is.

I haven't read the study, but if the statistics don't include death from complications of treatment then the overall US death rate resulting from prostate diagnosis might actually be a great deal higher.

Treatment can result in injury and death. If higher rates of diagnosis also lead to higher rates of uneccessary treatment, then the US might be doing a worse job of "treating" prostate cancer. And the result might not show up in the statistics.

JasonR:
Perhaps you could explain how one determines "incidence" without a diagnosis?

Posted by: flory | Oct 29, 2007 4:39:46 PM

Ezra wrote:
"So it's only causes that the health system should be preventing. What you're seeing aren't homicides but a lot of infant mortality, which America is absurdly bad at addressing among minority populations."

Hispanics in the USA have lower infant mortality than non-Hispanic whites. Asians in the USA have much lower infant mortality than whites. BTW people of west African decent tend to have more multiple births.

Have you checked the rates of infant mortality among aborigines in Australia, native Americans in Canada of Maoris in new Zealand lately? I wonder if there is data on infant mortality by race in Great Britain and France?

Also fertility treatments affect infant mortality rates and Americans use more fertility treatments.

Also:

http://www.opinionjournal.com/best/?id=110006153

“The United States . . . has the most intensive system of emergency intervention to keep low birth weight and premature infants alive in the world. The United States is, for example, one of only a handful countries that keeps detailed statistics on early fetal mortality--the survival rate of infants who are born as early as the 20th week of gestation.

How does this skew the statistics? Because in the United States if an infant is born weighing only 400 grams [14 ounces] and not breathing, a doctor will likely spend lot of time and money trying to revive that infant. If the infant does not survive--and the mortality rate for such infants is in excess of 50 percent--that sequence of events will be recorded as a live birth and then a death.

In many countries, however, (including many European countries) such severe medical intervention would not be attempted and, moreover, regardless of whether or not it was, this would be recorded as a fetal death rather than a live birth. That unfortunate infant would never show up in infant mortality statistics.>

The problems with medical care in the USA are it cost too much and it drags out death.

Posted by: Floccina | Oct 29, 2007 4:56:11 PM

Ezra,

How can you say, "America, you'll notice, doesn't do so well?" All I know is I see that graph, and the thing that jumps out at me is that, as always, the US leads the world. USA! USA! USA!

I have produced a more inspiring, patriotic version of the graph here .

Posted by: David S | Oct 29, 2007 4:57:53 PM

flory wrote:
"Perhaps you could explain how one determines "incidence" without a diagnosis?"

I can think of one autopsy but, I bet that is not used.

Posted by: Floccina | Oct 29, 2007 5:08:32 PM

JasonR:
Perhaps you could explain how one determines "incidence" without a diagnosis?

One can't. And your point is....?

Posted by: JasonR | Oct 29, 2007 5:13:12 PM

What is wrong with the voices in this ad? Rudy sounds weird, like this is his first time reading the script. And the announcer guy at the end sounds like an ogre.

Posted by: Random Dude | Oct 29, 2007 5:17:54 PM

Jason: The one drives the other. As example, here's the Cancer Research UK site (no political agenda) on incidence numbers: "Although there has been a huge rise in prostate cancer incidence over the last 20 years, the increase in mortality has been much less. Much of the increase in incidence is due to the increased detection of prostate cancer through the use of prostate specific antigen (PSA) testing and surgery for benign prostatic hyperplasia (BPH)." That effect is exactly what we're seeing in these numbers.

Posted by: Ezra | Oct 29, 2007 5:40:46 PM

JasonR, firstly I meant that no-one goes bankrupt as a result of medical fees, but in fact long term illness in any case doesn't lead to bankruptcy because once all secured loans have had the securities enforced, there's no benefit in seeking bankruptcy of a debtor who lives on benefits, except to the lawyers. Similarly, if there are any other assets to claim, compositions or execution against those assets will usually produce a better return. So, to clarify what I said: no-one goes bankrupt as a result of medical costs, and almost no-one except perhaps those with significant business obligations on their own account goes bankrupt as a result of illness.

Posted by: Marcin Tustin | Oct 29, 2007 5:43:21 PM

To be a wonky devil's advocate for a moment, Jason does have a point about incidence versus diagnosis; maybe Americans just get a hell of a lot more prostate cancer than brits. Absent some reason to believe this though, the diagnosis story works well.

My real issue is with the error around mortality rate; even with three hundred million samples, the ninety-five percent confidence level gives you error bars on the order of ten people out of one hundred thousand (if my mental math is correct), so I'm not crazy about those statistics. Is there a maybe a less-error-prone estimate to use?

Posted by: dennis | Oct 29, 2007 5:45:34 PM

And Guiliani cleverly avoids our infant mortality rate, longevity rate, and maternal mortality rate. All leading indicators of our rush to the bottom of health care.

Posted by: Kathleen O'Connor | Oct 29, 2007 5:48:30 PM

Jason: I apologise; you're right, I didn't stipulate what two things I was distinguishing between when I used the word "difference". I presumed a level of intelligence not in evidence. Let me try again:

"There is obviously a risk if you have existing financial obligations that you will no longer be able to meet if you become ill and can no longer work."

There's a difference between the financial obligations created by getting sick (healthcare costs) and the existing financial obligations that you created yourself by choice (a mortage/car loan/credit card). In the latter case, the market provides a mechanism to protect you and the lender against an unforeseen event.
In the former case, in the UK at least, there is no requirement for such a mechanism.

It's the reason why a Briton visiting the US buys travel insurance (because amongst other things they may get sick and be faced with huge medical bills) but an American visiting the UK doesn't have that risk: they get treated free of charge. No-one's going to ask for your insurance details and no-one's going to send you a bill.

I realise that it's helpful to your agenda to conflate healthcare costs with other financial costs in order to be able to say that people can go bankrupt under a public health system but the point, which you seem to want to ignore, is that the health system is not the cause of their bankruptcy.

In Britain, becoming ill does not on its own create a risk that you will go bankrupt. In the US, it can and it does. It really is that simple.

Posted by: Andrew | Oct 29, 2007 5:49:15 PM

Kathleen O'Connor wrote:
"And Guiliani cleverly avoids our infant mortality rate, longevity rate, and maternal mortality rate. All leading indicators of our rush to the bottom of health care. "

See my post above. It is not clear that the USA has worse numbers than anyone else.

Posted by: Floccina | Oct 29, 2007 5:56:19 PM

So Marcin's claim that "No-one goes bankrupt here because of illness" is false, isn't it?

Only if you're a mendacious quibbler. But that's the standard JasonRsole tactic: clutching at strawmen. And I see that he's already deployed the other dull smokescreen tactics we've come to know so well.

Let's just be clear about this, and get away from the tangents: Rudy's healthcare policy is 'eew, foreigners!' And that's being generous in the description. It's a good job that he went to suck up to Gordon Brown before making this ad, because it's the kind of thing that would earn him a punch in the face now.

Posted by: pseudonymous in nc | Oct 29, 2007 5:58:28 PM

Ezra,

If you insist on using the word "incidence" to refer to the rate at which the disease is detected in the population, what word do you propose we use to refer to the rate at which the disease occurs in the population? Presumably, you would agree that these are not the same thing. Let's call the former "Detected Incidence" and the latter "Total Incidence." Your argument that the U.S. health care system is no better at treating prostate cancer than the British health care system, and that the more aggressive screening done in the U.S. is a waste of resources, rests on the assumption that the Total Incidence of prostate cancer is the same in Britain and the U.S. You have no basis for that assumption.

Posted by: JasonR | Oct 29, 2007 6:09:48 PM

Andrew,

JasonR, firstly I meant that no-one goes bankrupt as a result of medical fees,

That's a very different claim than the claim you actually made ("No-one goes bankrupt here because of illness"). "Medical fees" are only part of the costs incurred due to illness. But even your new claim is most likely false. If a Briton chooses to obtain medical services outside the NHS, then obviously he may go bankrupt from the fees for those services.

The market provides a mechanism to protect you against both kinds of risk. That doesn't mean a person will (or can even afford to) use that mechanism. Insurance costs money. The point is that illness may cause bankruptcy due to either existing financial obligations or new ones created as a result of the illness.

Posted by: JasonR | Oct 29, 2007 6:33:20 PM

I think Ezra that you just fundamentally don't get it. To compare what the US spends to what Britain spends is to compare what free people decide to do with their income against what people are forced to do by the British government.

Its like comparing the US car industry, to the Soviet Union car industry. Central planners decided what the car would look like, how many people could fit and what it would cost. You got black and you liked it or you got a visit from the secret police.

In the US car sales flourish and grow in all directions because people are execising their free will, their choices. I am sure we Americans spent a ton more on cars then the Soviets did, that's not the point. Its who got to decide what they would spend and on what.

Posted by: Patton | Oct 29, 2007 6:33:50 PM

Andrew says: ""but an American visiting the UK doesn't have that risk: they get treated free of charge. No-one's going to ask for your insurance details and no-one's going to send you a bill.""

Well, then let's just pay for cheap flights to England and let them pick up the tab. What a great idea. Why its like magic, there's no cost, noone pays, that's incredible. Why don't we just do that for food, clothing, even jobs, we could sit on our arses at home, play Halo 3 and the government can stroke us a paycheck. WOW!. You've figured out a great sytem.

And this comment is interesting:
""as we have an aggressive screening process:""

How is it possible that we can have a more agressive screening then Britain when 48 million of us have no insurance and can't get healthcare.

Somehow we managed to institute a better screening ina voluntary system then in a downward directed beauracracy .

Posted by: Patton | Oct 29, 2007 6:38:37 PM

Andrew,

You're wrong about this too. Not only does the NHS charge visiting Americans for health care services, it even charges British citizens who are not ordinarily resident in the UK for health care services.

If you spent more time checking your facts and less worrying about my "level of intelligence" you might not keep making false statements.

Posted by: JasonR | Oct 29, 2007 6:41:29 PM

The left and the pro-state run healthcare have never told the truth about their statistics. They always include deaths caused by things like murder, car accidents, etc. which are much higher in the US having nothing to do with healthcare access or cost.

The most important numbers are for when you are ill with a disease and dying of a disease and you rely on healthcare to keep you alive,that is when 90% of the healthcare is spent during your entire life.

Posted by: Patton | Oct 29, 2007 6:43:39 PM

It's -- no pun intended -- crap.

What pun? Because the prostate is examined through the anus? I don't get it.

Wouldn't it be interesting to find out if the gold-standard care Giuliani got during his prostate cancer came while he was on government-provided health insurance?

As a tangent, there's a state legislator in Alaska now on trial for federal bribery charges. He allegedly begged his sugardaddy for cash because he ran up $17,000 on his credit card paying for neck surgery at the Mayo Clinic. This was while he was on the state employee health plan, which didn't cover the Mayo.

Posted by: Grumpy | Oct 29, 2007 6:52:13 PM

Speaking of the Frost family and the outrage of the left for conservatives who dared to look into the story of the Frost family. Hillary Clinton gave us another prop family when she was pushing Hillarycare.

My guess is Ezra didn't want us to scrutinize that family as well. But it a good thing people did. You see Mrs. Kathleen Bush was abusing her child, Jennifer, and then claiming she was sick. She was swept up and embraced by the left and the Hillary campaign.

Kathleen Bush – Hillary Clinton's once-proud and loud sister in arms -- was sentenced to FIVE years in prison on two counts of aggravated child abuse and one count of fraud. She also pled guilty to a separate count of welfare fraud for misrepresenting $60,000 in assets on Medicaid forms. "There was probably more abuse in this single case," lead prosecutor Bob Nichols noted, "than in all of the child-abuse cases I've prosecuted in my life combined."

Now Ezra will probably make the excuse that of course he would have wanted that family scrutinized, just not the Frost family. Luckily, people did care enough to scrutinize that case, or Jennifer Bush may well have died at the hands of her abusive Mother. A Mother empowered by the left and Hillary Clinton.

When Jennifer was separated from her mother for treatment at a Cincinnati hospital, the starved child feasted mightily on pizza, hot dogs, and chocolate bars. Meanwhile, authorities discovered that while the Bush family claimed poverty because of Jennifer's health problems, they had splurged on trips to the Bahamas and Disney World, house remodeling, and a new Harley-Davidson motorcycle.

I know, call us names, call us mean, call us stalkers; but Jennifer Bush lived, and that's thanks enough for us.

Posted by: Patton | Oct 29, 2007 7:17:00 PM

"You're wrong about this too. Not only does the NHS charge visiting Americans for health care services, it even charges British citizens who are not ordinarily resident in the UK for health care services."

I'm not saying you're a liar, but unless things have changed in the past 7-8 years (since I was living in the UK), then, well, you're a liar. When I incurred a stress fracture training in the hills of Scotland, it was treated free of charge and I never, ever got a bill. In fact, I had a conversation with the doctor about this. It was a conscious decision on the part of the NHS -- they couldn't in good conscious treat some patients for free and charge others. Plus, the "American" style, where they treat the poor, bill them, and then write off the debt was totally foreign. Either you charge people for treatment (and don't treat them if they can't pay), or you don't.

But like I said, that was several years ago. I'll check and see if this has changed.

(By the way, this is different from other EU countries, where they do charge nominal fees -- and by "nominal," I mean 1/10 or less of US healthcare fees.)

Also, you absolutely can determine incidence without diagnosis -- it's commonly done at autopsy. But the point is irrelevant, as the study Ezra cites defines incidence to BE "diagnosis."

Posted by: Joe | Oct 29, 2007 7:21:45 PM

Ah, I wasn't billed because I was a UK resident (though US citizen) at the time.

Though I note that emergency care is covered for all visitors. It's just nonemergent care that isn't -- probably to stop medical tourism.

Posted by: Joe | Oct 29, 2007 7:26:01 PM

Joe,

The National Health Service (Charges to Overseas Visitors) Regulations 1989

Posted by: JasonR | Oct 29, 2007 7:28:30 PM

"Speaking of the Frost family and the outrage of the left for conservatives who dared to look into the story of the Frost family. Hillary Clinton gave us another prop family when she was pushing Hillarycare.

Oh good God. The Jennifer Bush fiasco was 13 years ago, and the people who "discovered" the source of her illness were the doctors at the hospital who noticed that the girl seemed to get worse when her mother visited. This had nothing to do with scrutiny over the 1994 healthcare proposal whatsoever. Better monkeys, please.

Posted by: Joe | Oct 29, 2007 7:31:29 PM

Here's a link to Michelle Malkin's 2000 column that Patton is apparently quoting from.

I'm not seeing any reference to stalking helping matters. Had hospital officials been more aggressive in acting on their concerns in 1991, maybe the poor kid could have avoided some of the agony. I'm not going to suggest that overwork and underfunding had anything to do with that.

Posted by: Molly | Oct 29, 2007 7:32:58 PM

No, it had to do with scrutinizing the lefts props that you put before the public. Without that scrutiny Jennifer would be dead. But the left would then be using her death as even more reason to pass Hillarycare. They'd symbolically carry her body through the streets and shout shame, shame on you conservatives, you killed this poor child.

When all along it was your own wacko lefty Mom that did it.

We were told we had to apps Hillarycare to help people like Kathleen Bush, yeah, help her kill her child.

I love how you put out a near murderer who was torturing her child as a prop to take peoples freedom away and then you want to blame others.

Posted by: Patton | Oct 29, 2007 7:37:54 PM

Though I note that emergency care is covered for all visitors.

This is not necessarily true either. Under certain circusmtances, emergency care is free, but otherwise visitors have to pay for it. From the UK Department of Health's information for overseas visitors:

What do I have to pay for?
You will have to pay the full cost of all the treatment you receive, including emergency treatment, given by staff at a hospital or by staff employed by a hospital. However, there are some services that are free of charge to everyone:

Treatment given only in an Accident and Emergency (A&E) department or in a NHS Walk-in Centre providing services similar to those of an A&E department (excludes emergency treatment given elsewhere in the hospital);

Treatment for certain infectious diseases (excluding HIV/AIDS where it is only the first diagnosis and connected counselling sessions that are free to everyone);

Compulsory psychiatric treatment;

Family planning services.

Posted by: JasonR | Oct 29, 2007 7:39:32 PM

What about the fact that no dem frontrunner is offering a so-called "socialized medicine" British-style plan?

Thus, the whole ad is a giant straw man!

Posted by: bob | Oct 29, 2007 7:41:35 PM

JasonRsole seems not to know that while, technically, non-residents are subject to charges for NHS care, in practice it rarely occurs. What a frickin' surprise.

(Why? Because the system isn't set up to bill on a per-treatment basis.)

So, let's see if he can dive into his little bag of distraction dust and find someone who received a bill for care -- as opposed to the many Americans who have been patched up in A&E and sent on their way without paying a penny.

This isn't to say that Americans shouldn't carry travel insurance when in the UK -- it's a wise decision -- but it's not going to be the absolute top priority that it is for Britons visiting to the US. (I believe that $5m in medical expenses is the standard recommendation these days.)

Posted by: pseudonymous in nc | Oct 29, 2007 7:45:46 PM

while, technically, non-residents are subject to charges for NHS care, in practice it rarely occurs.

Evidence, please.

Posted by: JasonR | Oct 29, 2007 7:51:21 PM

Congratulations JasonR, you have discovered that tourists have to pay a fraction of any health care they need whilst in the UK.

Posted by: jmack | Oct 29, 2007 7:53:12 PM

Patton you say: "In the US car sales flourish and grow in all directions because people are exercising their free will, their choices. I am sure we Americans spent a ton more on cars then the Soviets did, that's not the point. Its who got to decide what they would spend and on what."

So this is the "free market", huh? How about the subsides for the the interstate highway system, the externalities of pollution, ethanol subsidies, and the war in Iraq to save cheap oil. Car flourish in the USA due to government intervention and the socialization of their true costs.

Posted by: maynardGkeynes | Oct 29, 2007 7:55:44 PM

"I think Ezra that you just fundamentally don't get it. To compare what the US spends to what Britain spends is to compare what free people decide to do with their income against what people are forced to do by the British government."

Yes, b/c buying private health insurance in the U.S. is just like buying a car.

Seriously, that's what you are arguing?

Posted by: bob | Oct 29, 2007 7:58:44 PM

If you could only buy one car model, or if you were lucky choose from one of two car models, based on your employer; and all of the cars models sucked and everyone hated them; and if you lost your job, you'd lose your car and be in danger of never getting another one if you were found to be a bad car owner; and if you were self-employed, the only car models you could buy were massively more expensive; then maybe Patton's comparison works.

Posted by: bob | Oct 29, 2007 8:02:55 PM

The point of our health care debate is the nature of the insurer: is it a for profit corporation or a local, state, or the federal government? While public entities do employ health care professionals, the vast majority of physicians are privately employed and will remain so.

It is my understanding that already over 50% of our health care expenses are paid by one government entitity or another. It is a very tough case to make that the millions on Medicare get care inferior to that of the patients with private insurance from the very same physicians.

In addition, many major public sector providers are staffed by private sector physicians. A patient at Ben Taub, part of Harris County Hospital District (Houston), receives the superb care of the staff of the Baylor College of Medicine.

The burden for those like JasonR: show how the private insurance industry in any way contributes more to successful treatment outcomes than programs like Medicare.

Posted by: Nat | Oct 29, 2007 8:37:51 PM

Evidence, please.

Ah, this is where JasonRsole says 'pshaw! anecdote!' when I say that I have personally ferried several Americans to A&E departments where they have been bandaged, stitched and otherwise patched up -- one soccer injury, one drunken slip on the pavement, one somewhat misguided decision to punch a window. None had to pay a penny.

Of course, there aren't going to be statistics to show that hospital staff habitually turn a blind eye to tourists coming in for emergency treatment. There will only be anecdotes.

I will, however, note that in the words of the minister responsible:

Successive governments have not required the national health service to provide statistics on the number of foreign nationals seen, treated or charged under the provisions of the NHS (Charges to Overseas Visitors) Regulations 1989, as amended, nor any costs involved.

So JasonRsole cannot prove, WITH EVIDENCE, that a single foreigner or non-resident has ever paid a penny for care that the NHS ordinarily provides free at the point of delivery.

Once again, he's got nothing. He has no idea how the NHS works in practice (warts and all) and desperately Googles away to distract attention from the topic of the post: that is, the fact that Rudy's healthcare policy is 'eew, foreigners!' and nothing more. So, c'mon: throw more pixie dust at us, you pathetic bullshitter.

Posted by: pseudonymous in nc | Oct 29, 2007 8:41:05 PM

I don't think Medicare recipients do get inferior care. They get lots of very expensive, very inefficient care because, thanks to its "low administrative costs," Medicare is so bad at making rational spending decisions. That's why Medicare's headed for bankruptcy. Did you see Ezra's chart of Medicare spending projections?

Posted by: JasonR | Oct 29, 2007 8:46:41 PM

pseudo,

So then, that would be no, you DO NOT have any evidence whatsoever that the NHS rarely charges overseas visitors for health care services.

You're just making things up, like you always do.

Posted by: JasonR | Oct 29, 2007 8:50:34 PM

And based on Ezra's chart, how much of the costs are specific to Medicare and how much relate to healthcare overall?
How, based on that chart, can you tell if Medicare does a better or worse job than any other insurer in restraining medical care costs?
And what on earth do "low administrative costs" have to do with Medicare's ability, or lack thereof, to make rational spending decisions?
Medicare's low administrative costs arise because it needn't maintain a marketing or sales staff or pay stock options to its management.

Posted by: flory | Oct 29, 2007 9:02:07 PM

To recap:

JasonR has refused to back down from his mistaken quibble about the original post, focused on a meaningless and obviously wrong quibble about medical care and bankruptcy in the UK, pointed out that there are limits to what NHS in the UK will pay for when it comes to non-citizens, and blamed pseudo for not showing data for services where data is not kept.

When bullshit is all you've got, I guess one has to go with one's strength.

Posted by: jmack | Oct 29, 2007 9:08:53 PM

I haven't said it is doing a better or worse job. I'm just pointing out that Medicare is already headed for bankruptcy, and that expanding it to cover more people would make that problem even worse.

And what on earth do "low administrative costs" have to do with Medicare's ability, or lack thereof, to make rational spending decisions?

You can't make rational spending decisions without investing the resources necessary to distinguish legitimate claims from fraudulent or exaggerated ones.

Medicare's low administrative costs arise because it needn't maintain a marketing or sales staff or pay stock options to its management.

And you know this, how?

Posted by: JasonR | Oct 29, 2007 9:13:07 PM

jmack,

JasonR has refused to back down from his mistaken quibble about the original post, ...

If you seriously believe that the difference between the rate at which a disease occurs in a population and the rate at which it is detected in that population is a "quibble," you really don't understand the issue at all.

The rest of your comments are similarly confused.

Posted by: JasonR | Oct 29, 2007 9:17:44 PM

"If what you're interested in is years of life lost due to the health care system, well, we have data on that too."

"All causes" includes homocides, suicides, etc., that have absolutely nothing to do with "the health care system," so no, we don't have those data. Try again, please.

Posted by: ostap | Oct 29, 2007 9:33:54 PM

flory - I may not agree with JasonR on much, but he's more right on the "low administrative costs" of Medicare - Medicare was designed to basically pay on claims without a lot of examination for fraud and waste; hence, it has a large fraud and waste problem. As it begins to look at Best Practices and not paying for unnecessary or wasteful care, it's likely that it's administrative needs will increase, and along with that, its costs. Medicare isn't the problem here; it's just that it's probably not the solution many on the left want it to be.

Posted by: weboy | Oct 29, 2007 9:54:46 PM

JasonR, you still can't/won't explain how one measures occurrences of prostate cancer without detecting them. I suppose I owe you an apology; it's not that your point is a "quibble," it's that you continue to peddle the same nonsense about it even after Ezra answered your concerns.

As for the rest about your "focus[ing] on a meaningless and obviously wrong quibble about medical care and bankruptcy in the UK, point[ing out] that there are limits to what NHS in the UK will pay for when it comes to non-citizens, and blam[ing] pseudo for not showing data for services where data is not kept," as well (I should add) as changing topics the instant that someone points out that you are flat wrong in your assertions, please enlighten me as to how I am mistaken; I don't want to be confused.

Posted by: jmack | Oct 29, 2007 10:20:01 PM

JasonR,

If I read you correctly you are saying that without hard data on the real incidence of cancer in the different countries we can't know which has the truly best survival rates.

You may be technically right and more data is always better but your objection doesn't appear to pass the common sense test. Do you really believe there is a strong chance that all these countries have widely different rates of incidence yet they all converge to roughly the same rates of population mortality rates?

Posted by: Gabriel | Oct 29, 2007 10:22:22 PM

Medicare is not without profit, just makes a different investor rich. Medicare Intermediaries, the bill payors, are usually publically traded companies that have huge margins on processing Medicare claims. Usually one of the Blue's or other large carrier in the reigion. They spend more money on studies and other friviouls exercises then any private insurer ever would, think ear marks and campagin contribution payback. Who hasn't seen an ad on TV for an electric wheel chair, those aren't marketed to individuals with private insurance and that many commercials don't come cheap. Medicare has billions in hidden cost they just don't include so it looks better. What Medicare waste easly covers the administration and profit of private insurance. Not to mention a heath insurer has one CEO Medicare has 437? However many politicians are in DC.

Posted by: Nate O | Oct 29, 2007 10:23:59 PM

Gabriel,

If I read you correctly you are saying that without hard data on the real incidence of cancer in the different countries we can't know which has the truly best survival rates.

That's right. Or, more generally, without data on the real incidence of cancer in different countries, we can't know how effective their health care systems are at successfully diagnosing and treating it. Ditto for every other cause of illness or premature death.

They don't all converge to roughly the same rates of population mortality rates. Mortality rates from different diseases (including different kinds of cancer) differ substantially between different countries. This isn't terribly surprising, since the incidence of various diseases (including cancer) is linked to environmental and lifestyle factors that also differ significantly between countries. For cancer, these factors would include the rate of smoking (lung cancer), exposure to the sun (skin cancer), and the levels of various carcinogens in the environment.

Posted by: JasonR | Oct 29, 2007 10:35:11 PM

So then, that would be no, you DO NOT have any evidence whatsoever that the NHS rarely charges overseas visitors for health care services.

See, even when JasonRsole's bullshit is blown away, he tries to dance like an little boy with no pants.

I can say from my own experience that foreign visitors have never been charged for A&E treatment provided free at the point of delivery. I can point to many other anecdotal accounts -- which is all there is, since there aren't any statistics kept. If you can find a substantial body of anecdotal accounts to show the contrary -- and we all know you've been desperately Googling, because that's the sum of your knowledge.

There have been a number of proposals to implement NHS charges for non-residents: it's the kind of thing that excites the right-wing tabloids, and the introduction of ID/'entitlement' cards may make a difference. But the real impediment is that there's no consumer-facing billing system in place for services that aren't normally billed.

(You will find that most fire departments aren't that good at billing, either.)

So, keep asking me to prove a negative, and I'll keep laughing at your bullshit, bullshitter. Can you come up with anything to refute the fact that the extent of Rudy's healthcare policy is to make 'eww' faces when talking about foreign systems?

Posted by: pseudonymous in nc | Oct 29, 2007 10:35:22 PM

JasonR,

On the chart we are debating here (male prostate cancer) THEY DO converge to roughly the same numbers (Japan is the exception). I am debating you honestly and assume reciprocity.

Again, I agree you have a logical point and more data would be welcome. But simple common sense (Or Occam's razor, if I remember my philosophy classes correctly) tells you that it's highly unlikely that the countries would have widely different rates of incidence yet such similar rates of mortality.

Look at the numbers. Japan aside the rates of reported incidence vary from 49 to 136 per 100k. Meanwhile the mortality rates are in much narrower range, from 26 to 31, and for 6 of the 7 countries it's from 26 to 28.

Posted by: Gabriel | Oct 29, 2007 10:46:55 PM

Gabriel,

On the chart we are debating here (male prostate cancer) THEY DO converge to roughly the same numbers (Japan is the exception). I am debating you honestly and assume reciprocity.

The chart provides information for a mere eight nations, and the (relative) consistency in mortality rates it shows disappears when more countries are added, as you can see from Figure 1.3 in this document. And that's just comparing nations within Europe. The variation in mortality is probably even greater when the comparison is expanded beyond Europe.

Posted by: JasonR | Oct 29, 2007 11:16:46 PM

I can say from my own experience ...

Ah, from your own experience, you say. Who can argue with that...

Posted by: JasonR | Oct 29, 2007 11:19:17 PM

Figure 1.3 does not say what you seem to think it says. It shows that there doesn't seem to be much relationship between incidence and mortality and that mortality, while it has a wider band than in the chart above, still tends to bunch up.

More data is better but I too have read what Ezra points out, that there does not seem to be much debate that a good part of the differences in incidence (or diagnosis if you prefer) appear to be due to more aggressive testing.

In fact, the link you provided agrees with the point Ezra and I are making:

"During the 1980s these rates rose consistently, with an acceleration of the trend in the early 1990s followed by a brief levelling off in the mid-1990s and another rising trend in the late 1990s. Some of this increase may be due to a real increase in risk, but increasing detection of the disease has almost certainly played a part."

Just look at figure 1.4 from your link.

http://info.cancerresearchuk.org/images/gpimages/cs_pro_f1.4

Posted by: Gabriel | Oct 29, 2007 11:35:17 PM

Who can argue with that...

Not someone impersonating a toddler dancing about with no pants, that's for sure.

Classic characteristics of the wingnut bullshitter: never admit you've been pwn3d, never confess to the ignorance you've displayed.

Posted by: pseudonymous in nc | Oct 29, 2007 11:43:45 PM

Gabriel,

Figure 1.3 does not say what you seem to think it says.

Yes, it does. And it directly contradicts the claim of a relatively constant rate of mortality.

It shows that there doesn't seem to be much relationship between incidence and mortality and that mortality, while it has a wider band than in the chart above, still tends to bunch up.

Huh? "Bunches up" where? Both incidence and mortality vary enormously. Estonia, Slovenia, the Czech Republic, Denmark, Latvia, Lithuania, Sweden and Belgium have mortality rates roughly double those of Romania, Bulgaria, Malta, Cyprus, Greece, Luxembourg and Italy. There's no consistency at all. The data is completely inconsistent with the hypothesis that the rate at which prostate cancer occurs is relatively constant across nations.

Some of this increase may be due to a real increase in risk, but increasing detection of the disease has almost certainly played a part."

I haven't denied that "incidence" (meaning "diagnosed incidence") is related to the rate of testing. Of course it is. But it is also related to the rate of occurrence--the rate at which the disease occurs in the population.

Just look at figure 1.4 from your link.

Figure 1.4 doesn't contain any data on variation in incidence or mortality across nations.

Posted by: JasonR | Oct 29, 2007 11:55:42 PM

JasonR,

If this is how you argue no wonder others lost their patience with you.

Your claim that we need to know more about the true incidence rates is correct BUT that does not mean we can't come to some conclusions based on the data we have. As Ezra and others have pointed out the experts in the field have made clear they attribute much of the differences in diagnosis rates to different levels of testing and NOT mainly to actual differences in 'true' incidence. In fact the link you provided has at the bottom several paragraphs on that same topic.

Substantial increases in incidence have been reported in recent years for many countries around the world, including the UK.

During the 1980s these rates rose consistently, with an acceleration of the trend in the early 1990s followed by a brief levelling off in the mid-1990s and another rising trend in the late 1990s. Some of this increase may be due to a real increase in risk, but increasing detection of the disease has almost certainly played a part.

An analysis of prostate cancer incidence trends in Scotland concluded that much of the apparent increase in cancer incidence between 1981 and 1996 was caused by increased detection – before 1989 through increasing rates of transurethral resection of the prostate (TURP) and afterwards through the rising use of PSA testing.

Analyses for other countries including the USA and Australia have also pointed to increased detection being a factor.

In the USA widespread PSA testing on asymptomatic men from around 1986 resulted in dramatic increases in incidence (an 82% rise between 1986 and 1991) 20 and it is estimated that more than half of US white men aged over 50 have had their PSA level tested.8 In western Europe the widespread use of PSA tests began a few years later, in around 1989–1990, but the level of population screening is still thought to be much lower than in the USA. Cases may also be picked up at post-mortem, which most cancer registries will record.

This is pretty clear. Experts on the field see the difference between the reported incidence rates as the result in good measure of the different testing procedures.

In any case we have lost track of the main point here. Giuliani claimed that the survival rate for prostate cancer patients is dramatically higher in the UK than in the US. But he has nothing to back that up. THAT is the core point here.

Your hypothesis is that Giuliani's claim may be true if it turns out that the US has much higher real rates of incidence than the UK and so the similar mortality rates would indicate better care in the US. But you have no data to back that up. The experts in the field, including the ones you linked to, agree that different testing procedures is the big explanatory variable. If and when you provide data backing up your hypothesis I will gladly read it. In the meantime the consensus among the experts is one that makes clear Giuliani's claim has no standing.

Posted by: Gabriel | Oct 30, 2007 12:11:57 AM

Just to be clear, here's what it boils down to.

1) Giuliani made a claim he can't back with data.

2) You have an interesting hypothesis that if true would make Giuliani's claim true but no hard data to support it.

Posted by: Gabriel | Oct 30, 2007 12:26:03 AM

Gabriel,

You keep saying this as if I have said otherwise. Yes, some of the difference in the diagnosed incidence of prostate cancer between the U.S. and some other nations is likely due to differences in screening. Some of it. But we don't know how much of it is due to screening differences and how much is due to differences in the rate at which the disease occurs in different national populations. No data has been presented that would allow us to quantify those relative contributions even approximately. And therefore, there is no empirical basis for the claim that the U.S. health care system is no better than the health care systems of other nations at treating prostate cancer. There is no empirical basis for the claim that the extra money we spend on testing is wasted.

Posted by: JasonR | Oct 30, 2007 12:41:34 AM

JasonR,

there is no empirical basis for the claim that the U.S. health care system is no better than the health care systems of other nations at treating prostate cancer.

Remember, this whole post is about what Giuliani claimed. We can have dozens of related debates but the core issue here are Giuliani's claims. And they remain unsubstantiated. Giuliani made the claim so he should back it up.

Posted by: Gabriel | Oct 30, 2007 12:45:26 AM

Gabriel,

I haven't said anything about what Giuliani said. I'm responding to Ezra's suggestion that the only significant difference between the U.S. and other countries with respect to prostate cancer is that we are more aggressive about testing for it. We certainly are more aggressive about testing, but that greater vigilance may also be saving many lives that would otherwise be lost if we did less testing. And of course, the benefits of prostate cancer treatment are not limited to preventing death. Treatment can also significantly improve the patient's quality of life.

Posted by: JasonR | Oct 30, 2007 12:57:09 AM

JasonR,

In that case this may be yet another example of small differences of opinion blown out of proportion.

I agree with you that we can't say with certainty that the US is no better than other countries in the treatment of prostate cancer based on the information presented here. But given that all the experts put so much weigh on increased testing as an explanation for the differences in incidence rates, and that the rates have skyrocketed in countries after new testing procedures were utilized (82% rise in 5 years in the US according to the link you provided) it's hard to pretend the evidence provides no guidance whatsoever. While it's true that I have not seen any expert quoted breaking down what percentage is due to testing and what to real differences the combination of the data indicates that it is most likely heavily weighed toward the 'testing' explanation.

Posted by: Gabriel | Oct 30, 2007 1:04:37 AM

Gabriel,

I agree with you that we can't say with certainty that the US is no better than other countries in the treatment of prostate cancer based on the information presented here.

It's not merely a matter of "not being certain." There's no basis at all for the assertion that the extra money and effort we spend on testing for prostate cancer is not buying us equivalent benefits in saved lives and reduced suffering.

But given that all the experts put so much weigh on increased testing as an explanation for the differences in incidence rates,

What are you talking about? What "all the experts?" What "weight?" Here's what the American Cancer Society says:

More testing in some developed countries likely accounts for at least part of this difference [in incidence of prostate cancer], but other factors are likely to be important as well.

"...at least part..." That's "weight," is it? The ACS also says that risk factors for prostate cancer include age, race, diet, and obesity. These factors vary significantly across nations, so we can expect that the rate of occurence of the disease probably differs significantly also.

Posted by: JasonR | Oct 30, 2007 1:35:33 AM

And then of course there's the second part of Ezra's post, in which he broadens the discussion to the relationship between a nation's health care system and the "potential years of life lost" to its population. Ezra claims that the U.S. "doesn't do so well" by this measure either, because we spend so much on health care relative to other countries but actually lose more potential years of life.

The problem with this argument is that it also completely ignores differences between nations in the rate of occurrence of diseases and other things that can cause premature death. The U.S. health care system may be twice as good as, say, Canada's health care system at saving the lives of gunshot victims. But if the rate of gunshot wounds is three times higher in America than it is in Canada, America will still have a higher gunshot wound mortality rate, even though it's much better at treating such wounds.

Posted by: JasonR | Oct 30, 2007 1:50:36 AM

It's abit late, but I want to point out that Ezra already covered this topic in 2006. Might be some additional info in that article:
http://ezraklein.typepad.com/blog/2006/05/i_wonk_because_.html

Posted by: Gray | Oct 30, 2007 5:07:34 AM

OK, sry folks, but I can't resist reposting my comment from 2006:

"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."

Well, sry again, but I also have to quote Duke Nukem:
"Damn, I'm good!"
:D

Posted by: Gray | Oct 30, 2007 5:10:08 AM

"If this is how you argue no wonder others lost their patience with you."

Indeed. I know teenagers who argue in better faith and are less irritating about it.

Posted by: jmack | Oct 30, 2007 6:35:51 AM

But that's not "incidence." Incidence is the rate at which the disease occurs in the population, not the rate at which it is detected.

Incidence is the number of new cases that occurs in the population; Incidence is directly related to detection/diagnosis because that is how new cases are identified. Your "argument" is completely semantic and obtuse.

*We have higher incidence because we have more aggressive screening.

**No, we have a higher rate of diagnosis. That is probably in part because of more aggressive screening, but it may also be in part because prostate cancer occurs more frequently in American men than in British me

Ezra is correct and you are wrong, again. The incidence rates are indeed higher in the US because of PSA screening and better early detection tools. Prior to 1990, before PSA screening was approved, incidence rates were under estimated and were masked because of prevalent cases existing in the population. The lower incidence rate was masked (~100/100K) because prevalent cases were not being diagnosed/identified and hence the incidence was diminished/under estimated. Post 1992 the incidence rate increased from 100/100K to about 170/100K because of screening and better detection rates. Jason, Please don't let facts stand in the way of a good hissy git though. You are wrong. Deal with it.

Incidence rates-->http://img89.imageshack.us/img89/18/incidenceratesdn5.jpg

Posted by: Dr. Matt | Oct 30, 2007 9:56:07 AM

Yes, some of the difference in the diagnosed incidence of prostate cancer between the U.S. and some other nations is likely due to differences in screening. But we don't know how much of it is due to screening differences and how much is due to differences in the rate at which the disease occurs in different national populations.

"diagnosed incidence"? LOL. Is there an "undiagnosed incidence"? Seriously, it's obvious you are way over head. You clearly do not even have a rudimental grasp of basic epidemiologic principles. AGAIN, incidence is directly related to diagnosis. There is no way around it. The US incidence rates are directly related to early screening and detection. The reason why the 5-year survival rates from prostate cancer in the U.S have increased to nearly 100% is because of PSA screening, early detection, and investments made in research from federal funding. If reich-wingers had their pro-death ways, they would cut funding to the NIH/NCI and have every man, women, and child fend for themselves. This has NOTHING to do with "socialized medicine". You are unarmed.

Posted by: Dr. Matt | Oct 30, 2007 10:03:55 AM

There's no basis at all for the assertion that the extra money and effort we spend on testing for prostate cancer is not buying us equivalent benefits in saved lives and reduced suffering.

OK Jason, now you are just being obtuse. Giuliani claimed that the UK's survival rate was much worse than the US's. Ezra correctly pointed out that both countries have similar mortality rates and that the difference in incidence rates is most likely due to differences in testing. You claim there is no basis for this second point and while I agree that no one has linked to something that PROVES it conclusively the prepondrance of the evidence is clearly in its favor. How do you explain the almost doubling in the US incidence rate in 5 years right after the introduction of a new test? Are you claiming it was just coincidence?

You make some good analytical points that I think others here should have acknowledged. But you destroy that when you claim we have NOTHING to decide what proportion of the difference in reported incidence rates is based on real differences and not in testing patterns. That is simply not true. The dranmatic increase in several countries of reported cases right after new testing was implemented combined with little to no change of the mortality rates makes it clear that the most likely scenario, by far, is the one Ezra and others are claiming.

For your alternative hypothesis to be true the US would have had to see a dramatic increase of cancer risk, coincidentally right at the same time a new test was implemented, and yet have almost no impact on the mortality rate. What do you think are the chances of that?

Posted by: Gabriel | Oct 30, 2007 10:11:00 AM

US would have had to see a dramatic increase of cancer risk, coincidentally right at the same time a new test was implemented,

The US DID observe a dramatic increase of incidence coincidentally right at the same time a new test was implemented. Here are the data --> http://img89.imageshack.us/img89/18/incidenceratesdn5.jpg

yet have almost no impact on the mortality rate. What do you think are the chances of that?

The reason why the survival rate is nearly 100% is directly attributed to early screening. The 5-year survival rate in the 80s was around 75%, now since screening and early detection has been widely implemented in the US, that 5-year survival is nearly 100%.

Posted by: Dr. Matt | Oct 30, 2007 10:16:52 AM

P.S Early detection via PSA testing and DRE increases survival (and decreases mortality) because we can diagnosis cases at earlier stages when the cancer is much easier to treat and much less likely to metastasize.

Posted by: Dr. Matt | Oct 30, 2007 10:20:53 AM

"P.S Early detection via PSA testing and DRE increases survival (and decreases mortality) because we can diagnosis cases at earlier stages when the cancer is much easier to treat and much less likely to metastasize."

I thought so, too, Doc Matt, but then, how do you explain this doesn't show up in statistics???

Posted by: Gray | Oct 30, 2007 10:37:18 AM

"Dr" Matt,

Ezra is correct and you are wrong, again. The incidence rates are indeed higher in the US because of PSA screening and better early detection tools.

No, we don't know why incidence rates are higher in the U.S. It is likely a combination of both higher rates of testing and a higher rate of occurrence of the disease in the population.

diagnosed incidence"? LOL. Is there an "undiagnosed incidence"?

Yes, of course there is. Men who have prostate cancer but have not been diagnosed with it are cases of undiagnosed incidence of the disease. Only about half of American men over 50 have even had the PSA test.

Posted by: Dr JasonR | Oct 30, 2007 12:09:36 PM

Gabriel,

You're the one who's being obtuse. You previously cited the very similar prostate cancer mortality rates in a sample of eight countries as evidence that the disease is not likely to be occurring more often in Americans than in men of other countries.

I then pointed you to a larger sample of countries, showing that the convergent mortality rate disappears when more countries are compared. This blows your hypothesis out of the water. Rather than admit that, you changed the subject.

Cancer experts also say that risk factors for prostate cancer include age, race, obesity and diet. These factors vary significanctly between countries, which again suggests that the rate of occurrence of prostate cancer also varies significantly between countries. Gray just made the same point.

The bottom line is that we don't know how commonly prostate cancer occurs in American men as compared to British men or French men or Italian men or any other country.

You keep mentioning that diagnosed incidence rose dramatically as testing rose dramatically. For the umpteenth time, this is not in dispute. This is entirely expected. The harder you look for the disease, the more cases you are likely to find. The issue is the rate of occurrence of the disease, not the rate of detection.

Posted by: JasonR | Oct 30, 2007 12:28:01 PM

The current US Health Care model for financial reimbursement is based upon what Medicare does. From preauthorization for medications/diagnostic procedures to reimbursement based upon diagnosis/procedure codes. Any of the "rational spending decisions" made by the other insurance providers are a direct result of following a decision that Medicare has already made.

Posted by: Dick | Oct 30, 2007 12:33:39 PM

"Only about half of American men over 50 have even had the PSA test."

Uh, come on, Jason, most of these won't show up in statistics,and that's what we're talking about.

Posted by: Gray | Oct 30, 2007 12:35:37 PM

"These factors vary significanctly between countries, which again suggests that the rate of occurrence of prostate cancer also varies significantly between countries."

Well, I have to agree, this seems to be correct. And that's why this statistic isn't conclusive on whether healthcare is better in US than in the rest of the world. Even if Ghoulani wouldn't be spinning the numbers, this is simply no good evidence.

Posted by: Gray | Oct 30, 2007 12:41:29 PM

Well, I have to agree, this seems to be correct. And that's why this statistic isn't conclusive on whether healthcare is better in US than in the rest of the world.

I never suggested it was. I'm arguing against Ezra's claim that the the extra resources the U.S. devotes to prostate cancer testing are wasted. That additional testing may be saving lives and reducing suffering. We won't really know until we have good data on just how commonly prostate cancer occurs in American men compared to men in other countries that do less testing.

Posted by: JasonR | Oct 30, 2007 12:49:03 PM

Well, this thread has run a bit amuck.

Just to get all anecdotal, I spent 6 months studying in London, '72-'73. My doctor visits might have cost me a minuscule co-pay but were essentially free.

Staff explained that they were supposed to extend free coverage to citizens of those countries who extend free coverage to British citizens. Reciprocity and all that. Technically, I should have paid in full, but the staff blew it off.

I realize it was a long time ago and my medical needs were minor, but I received timely, competent, affordable care with exactly zero bureaucratic bullshit. These days I count my blessings if I get 2 of the 4 in Austin.

Posted by: Nat | Oct 30, 2007 1:04:26 PM

JasonR,

No, I did not have an hypothesis blown out of the water for the simple reason I had none. I merely mentioned the 8 countries because that was the evidence in front of me in this post. You expanded that by including information on more countries and that's fine. But to decide if the new information shows a (relative) concentration of mortality rates it would require more work than I am interested in doing and, in any case, was not the issue I was debating.

Part of what we have is the normal cross talk of many online debates. And part of it are some of the good points you make, about the need for more data. But that does not change or challenge the CORE point we have here and the one I was referring to.

To repeat, while you are correct that we have incomplete information on how much of the difference in reported incidence is from true differences and how much is from testing that DOES NOT mean we have no information at all. Am I clear on this? (don't mean this in any mocking term by the way). It seems I am not because you wrote that :

You seem to think I don't get what you are trying to say. I do undertsand your point. What I don't agree is with your claim that:

I'm arguing against Ezra's claim that the the extra resources the U.S. devotes to prostate cancer testing are wasted. That additional testing may be saving lives and reducing suffering. We won't really know until we have good data on just how commonly prostate cancer occurs in American men compared to men in other countries that do less testing.

Your point is correct in the sense that we don't have conclusive evidence. I have already acknowledged that. But this is not a coin-toss question. It's not as if the two scenarios (yours and Ezra's) are equally likely. The evidence is such that Ezra's point is much more likely to be true. THIS is the point you don't address.

Why is Ezra's point more likely to be true than your hypothesis? Because for your argument to be correct you need to explain why the US saw an 82% increase in reported cancer rates after the introduction of new testing but did not see an equal increase in mortality rates. And why that same phenomenon (new tests, increase in cancer detection, no major changes in mortality) is something we see in other countriesm as well such as the figure 1.4 from the UK I referred to above. Ezra's argument is much more likely to explain this than yours.

Ezra's claim is simpler and has better explanatory power than yours. the increased testing caught a lot of cancer that would otherwise have gone undetected but that mostly would not have resulted in deaths. Hence the unchanged mortality rates. This explanation fits the numbers and does not require heroic assumptions about our cancer fighting techniques like your does.

Posted by: Gabriel | Oct 30, 2007 1:32:56 PM

Gabriel,

No, I did not have an hypothesis blown out of the water for the simple reason I had none.

Of course you did. You said: "Do you really believe there is a strong chance that all these countries have widely different rates of incidence yet they all converge to roughly the same rates of population mortality rates?" And you made a big deal of the fact that the mortality rates in "all of these countries" (all seven of them) were within a percentage point or two of each other. You attached great significance to the common mortality rate. But when I showed you that the mortality rate varies dramatically when more nations are included, rather than rethink your hypothesis, you tried to deny that the information I cited changed anything and you changed the subject. And you have the nerve to accuse me of being obtuse!

It's not as if the two scenarios (yours and Ezra's) are equally likely. The evidence is such that Ezra's point is much more likely to be true. THIS is the point you don't address.

You still don't seem to understand. The "two scenarios" are not in conflict. Some of the difference in incidence is likely to be due to differences in testing. And some of it is likely to be due to different rates of occurrence. We have no information that would allow us to quantify the relative contribution of each factor. You have presented nothing to support the conclusion that the rate of occurrence of prostate cancer is not signficantly higher in the U.S. than in other countries. The fact that the occurrence of risk factors for prostate cancer varies significantly between different countries implies that it is unlikely that the disease occurs at approximately the same rate in those countries. Even Gray seems to understand this. I don't know why you can't.

Posted by: JasonR | Oct 30, 2007 2:10:30 PM

Because for your argument to be correct you need to explain why the US saw an 82% increase in reported cancer rates after the introduction of new testing but did not see an equal increase in mortality rates.

This is utter nonsense. Nothing about "my argument" implies that mortality rates should increase as the rate of testing and diagnosis increases.

Posted by: JasonR | Oct 30, 2007 2:14:47 PM

Let's see:

1) On the bunching of mortality rates. I first commented on the evidence available, the 8 countries. You expanded on that and, crucial point, YOU decided that the new evidence (the inclusion of the 27 European countries) contradicted what I wrote. I don't agree with that. I look at that chart and see more bunching in the mortality rates than I do on the incidence rates. But to address that more fully I'd need to do some stat analysis and I am not really interested in that. So let's leave that aside. It's not crucial to the main point.

2) You claim that the two scenarios are not in conflict. That I agree, at least they are not fully in conflict. What I don't agree is when you claim we have no information to quantify the relative contributions. We do have some information. But you disagree and we are not getting anywhere.

Posted by: Gabriel | Oct 30, 2007 2:54:15 PM

Gee, JasonR's "undiagnosed incidence" seems eerily similar to Rummy's "unknown unknowns"...

How can you measure "undiagnosed incidence"? It seems to me that by definition, it will *always* be an estimate.

Anyhoo, JasonR and Patton have done a good job of clouding the discussion and distracting us from the Ezra's actual points.

Rudy's claim of 44% vs 82% survival rates is unsupportable from the stats. He's using the increased incidence rate to skew the result to support his stand. We would need to see the survival rates of those actually diagnosed to make a valid comparison.

The US spends at least twice per capita compared to the UK; while not covering 15% of the population. If the US system is the best in the world, you would expect to see significantly better metrics. I don't see them.

As for the bankruptcy issue, the point that JasonR refuses to admit is that getting sick and requiring hospital care does not lead to the kind of financial burden in countries with government-run health care that it does in the US. A 2005 study published in Health Affairs found that roughly half of all U.S. bankruptcies are caused by medical bills. And a large chunk of those bankruptcies happened to middle-class families that HAVE insurance!

If JasonR can google up some corresponding stats for the UK, I'll gladly take a look at them.

Posted by: Court Jester | Oct 30, 2007 3:04:28 PM

Gabriel,

It does contradict what you wrote. The eight countries on which you based your hypothesis are not representative. The mortality rate is found to vary dramatically when more countries are included in the comparison. But rather than revisit your hypothesis in light of that new information, you pretend that nothing has changed.

What information? We have information that mortality rates from prostate cancer differ dramatically between different countries. If mortality rates are correlated with occurrence rates, that implies dramatic variation in occurrence rates between countries too. We also have information on risk factors for prostate cancer. The occurrence of various risk factors also differs dramatically between different countries. That also implies that the rate of occurrence of prostate cancer differs dramatically between countries. That's two independent types of evidence for dramatic variation in prostate cancer rates between countries.

Posted by: JasonR | Oct 30, 2007 3:54:08 PM

The US spends at least twice per capita compared to the UK; while not covering 15% of the population. If the US system is the best in the world, you would expect to see significantly better metrics.

Significantly better metrics of what? If you think you have a good set of metrics that measure the effectiveness of the health care systems of different nations at preventing, diagnosing and treating the causes of poor health and premature death, then please present them.

Posted by: JasonR | Oct 30, 2007 3:58:06 PM

I'm not going to do your work for you, JasonR. Since you have chosen to quibble over semantics, I'll try to reword my point to avoid confusion.

The US spends more per capita on health care than any other country in the world, and specifically 2-3 times as much as various countries in the EU. If, as claimed, it's the *bestest* system in the world, it should be childishly simple to find clear evidence that it's better.

There should be a cornucopia of data that clearly shows the superiority of the US private system. Someone like yourself, with a few dozen keystrokes, should be able to conjure up link after link of compelling charts and graphs to silence all of our arguments. It should be a veritable "shock and awe" of statistics. A deluge, a torrent...

Instead we get arguments over terminology, interpretation and semantics. Not much in the way of hard data to show that a country that is spending an increasing percent of its GDP on health care IS getting good value for it's money.

Posted by: Court Jester | Oct 30, 2007 4:58:24 PM

Jester,

I'm not going to do your work for you, JasonR.

It's not my job to look for evidence for your claims. That's your job.

I didn't claim it's the "bestest" system in the world. If you're claiming it's worse (or is that "worstest"?) than an alternative system, and that we should adopt that alternative system instead, it's up to you to produce evidence establishing the superiority of that alternative system. Do you have any such evidence? Do you have evidence that any alternative system is better at preventing, diagnosing and treating the causes of poor health and premature death?

If you cannot back up your claim that there's a better alternative to our current system, then we need not take it seriously.

Posted by: JasonR | Oct 30, 2007 6:23:26 PM

Let me step back and suggest the level of detail you have reached in debating this ad is irrelevant and offer instead the following: this ad isn't about prostate cancer. It's about framing the electoral choice as follows: do you want an America that becomes more like Europe or do you want an America that continues to conduct itself differently from Europe. This ad is obviously trying to position Democrats as "let's make America more like Europe" and Republicans with the "I believe in the American way of doing things" position. I am not predicting whether it will work or not across a sufficient number of the electorate, but there is a class of voter who will instinctively align themselves with the latter camp. And I don't think responding to the ad by debating whether incidence or diagnosis is the right term,or asserting that Britain is just as good, is going to be the optimal kind of response for the left.

Posted by: Mt57 | Oct 30, 2007 6:23:52 PM

Even if the NHS did charge full price to overseas visitors, the prices they do charge are not what a hospital here in the US would. Not even close. Which. is. the. point.

Posted by: Joshua | Oct 30, 2007 7:10:57 PM

Once again, JasonR, you want to turn things around. Many here, including myself, have made the mistake of thinking you have an actual point, rather than just stirring things up; arguing about minutia, and telling everyone else that they need to do more research and provide you with more facts to argue against.

I doubt you'll agree, but maybe we can find common ground in saying that none of the data presented to date shows that the current US system is clearly better or worse than the UK system. (Side point - the UK system is not the best representative of single payer/government run care).

So here's my challenge to you: tell us what you *really* think. Do you think the 2 systems are basically the same, or do you think that one is "better" than the other?

I know it's easier to sit back and try to shoot down everyone else's arguments; but try being proactive for a change, not reactive.

Posted by: Court Jester | Oct 30, 2007 10:17:15 PM

I doubt you'll agree, but maybe we can find common ground in saying that none of the data presented to date shows that the current US system is clearly better or worse than the UK system.

No, I think there's a ton of evidence that the U.S. system is better.

But you're the one who favors major reform of our current system. I'm not sure if you're a single-payer loony, or if you just want some more modest Hillary-style changes. But either way, it's up to you to present evidence that such a change is justified. You haven't done that. No one has done it. No one has even made a serious attempt to do it.

Posted by: JasonR | Oct 30, 2007 10:45:13 PM

Mt57: I agree with you that "there is a class of voter who will instinctively align themselves with the latter camp". They're the 25% who still blindly supporting this administration.

I would suggest that the left work to reframe the issue. The Republican plan for health care is, quite simply, the same "solution" that they had for Social Security - privatization and tax breaks. We saw how well that went over.

Thousands of US soldiers have died, thousands more are maimed, and tens of thousands of Iraqis are dead because Bush and his administration were determined to "stay the course". Put plainly, they're too stubborn to admit mistakes and fix them. So the carnage will continue.

Back in the US, the health care system is also lurching towards failure. As mentioned previously, a 2001 study concluded that roughly *half* of bankruptcies were caused by medical expenses, even though many of those involved had insurance. That's up from an estimated 8% in 1981. There are millions of families who are one serious illness or injury away from financial ruin. Ironically, the final push to a single payer system will likely come from corporations. Rising health care costs make it difficult for them to compete internationally. Health care costs were the key issue in the recent GM/Ford dispute.

Have Americans become so self-absorbed that they'll dismiss new ideas simply because they come from somewhere like, *GASP*, Europe? I don't think so, but then again, I didn't think Bush would get re-elected.

Posted by: Court Jester | Oct 30, 2007 10:57:17 PM

Jester,

Er, no it didn't. You're misrepresenting the findings of that study.

But you're right that "many of those involved had insurance." A majority of them, in fact. So universal health insurance wouldn't do much to reduce the medical-bankruptcy problem, because most people who file for such bankruptcies already have insurance.

By the way, a different set of researchers, using the same data, concluded that medical bills are a factor (not necessarily the biggest factor, just a factor of some kind) in only 17% of bankruptcies.

Posted by: JasonR | Oct 30, 2007 11:11:06 PM

JasonR: There, doesn't it feel good to admit where you stand? Not that it was really a secret.

Now, I knew that you wouldn't be able to bring yourself to agree with anything I said; but you did realize that I qualified my statement with "none of the data presented to date", right? Did you present us with any of the "tons of evidence" that the US system is better? I must have missed it. In fact, that was my challenge at 4:58. If you have "tons" of compelling evidence supporting your case, why haven't you shared it with us?

I think the current system is approaching a breaking point, and that it needs to be changed. The ever-increasing cost of the war in Iraq combined with the ever-increasing cost of health care, if not dealt with, will destroy the US economy. As I see it, the choice is to adapt or to be left behind.

Posted by: Court Jester | Oct 30, 2007 11:30:52 PM

If you have "tons" of compelling evidence supporting your case, why haven't you shared it with us?

Because I'm not the one trying to change our health care system. You are. Your argument is, "I don't have any evidence, but trust me on this." Not exactly compelling.

The latest estimate of total spending on the wars in Iraq and Afghanistan as well as all the domestic spending on the War on Terror since 2001 amounts to less than 1% of U.S. GDP over the same period. I don't think the economy is in much danger.

Posted by: JasonR | Oct 30, 2007 11:38:01 PM

"The current US Health Care model for financial reimbursement is based upon what Medicare does. From preauthorization for medications/diagnostic procedures to reimbursement based upon diagnosis/procedure codes. Any of the "rational spending decisions" made by the other insurance providers are a direct result of following a decision that Medicare has already made."

Every statement in here is wrong. Pre Cert are in no way linked or even close to Medicare, the mechanisms and procedures for precert of private plans is usually pre service, thus the pre in pre-cert where Medicare is done via guidlines and post service.

Medicare uses DRGs which are extremly rare in private insurance. Medicare started covering experimental tretments a couple years back, part of the reason for sky rocketing cost, most private plans specifically disallow this.

Posted by: Nate O | Oct 31, 2007 12:21:07 AM

JasonR: There, doesn't it feel good to admit where you stand? Not that it was really a secret.

Posted by: Court Jester | Oct 31, 2007 12:34:04 AM

Just a comment about the variability of mortality statistics across a wide range of countries. Jason contends that the mortality rates vary dramatically, and that some countries have double the rates of others, which is true as far as it goes.

However, the contention of Ezra, Gabriel, etc., that the statistics tend to cluster is reasonably justified if you look at the actual statistics for the full set of countries cited by Jason. From a download of the statistics, the median, mean, and standard deviation of mortality rates across 12 non-Asian countries in Figure 1.2 are respectively 18.1, 19.1, and 4.2 per hundred thousand, with a relative standard deviation (RSD) of 22 %, barely statistically distinguishable from the US mortality rate. (If we include the Asian countries, the standard deviation increases significantly, and any deviation of the US rate from the group cannot be statistically detected.)

If we look at the data for 28 European countries in Figure 1.3, we find somewhat higher median, mean, and standard deviation of 24.5, 25.8, and 7.6, yielding an RSD of 29 %, largely as the result of 6 countries with mortality rates in excess of 35. While there is not a tight fit, there is certainly significant clustering, especially given the high variability of processes subject to such a wide range of uncontrolled factors as human health.

Also disturbing is the trend shown in Figure 1.4, which indicates that the European mortality rate over time from 1975 to 2005 has remained stubbornly resistant to change despite the increased incidence of early detection, and is in fact slightly higher in 2005 than it was in 1975. This suggests that the highly ballyhooed PSA screening program is not delivering the cost/benefit ratio that we would like to believe. The ratio of mortality to detected incidence has declined, but not the absolute rate of mortality, which is a better gauge of success.

Posted by: Jay | Oct 31, 2007 1:50:36 AM

Congratulations, JasonR, you've finally reached troll status! You are the epitome of the current GOP mindset. Since I'm quite sure you're not as stupid as you present yourself, you have apparently *chosen* to ignore facts and stick to unsupportable talking points. The problem is called projection. It's common among many in the Republican party. You are the one who claims to have "tons of evidence" to support your point of view, but refuse to share it with us because, well, just because. To paraphrase your own words, you're saying "I have tons of evidence, which I won't show you, but trust me on this".

I have supplied supporting documentation. You may not like it, or agree with it, but I supplied it. You claimed I misrepresented it, but (what a surprise!) didn't supply any more detail than that vague accusation.

You then state that someone else interpreted the same data and got difference results, but (another surprise!) didn't supply any link for that study.

You were then able to take the fact that insurance doesn't prevent medical bankruptcies and twist it around to claim that it supports your argument against single payer programs.

Previously, you actually tried to pretend that getting sick enough to require a stay in hospital in the EU is kind of financial burden that it is in the US. Facts be damned!

Sure, you say, the US economy can absorb a couple of trillion for the Iraq war (and the cost of looking after the thousands of wounded soldiers from now on) and the increasing cost of health care. It looks like the Chinese economy can, but the US ecomony is not unsinkable.

Like the captain of the Titanic, you refuse to admit that health care and the Iraq war are serious problems facing the US. "Stay the course". Great strategy. Oh, I guess you like the idea because in your mind, NOT changing the way things are means you don't have to present any justification. You can just sit back and snipe at those who are offering ideas for consideration.

Health care should not be a partisan issue. Even Republicans get sick. Hell, Guiliani benefitted from "government-run" health insurance. Funny how the rules don't apply to those in power. After all, "all animals are equal but some animals are more equal than others".

Posted by: Court Jester | Oct 31, 2007 10:48:11 AM

So, lot's of hot air blasting around, but here's the acid test:

1) Which of you guys who think aggressive screening is irrelevant will commit now to *not* having it, when you turn 50

2) If aggressive screening is useless, why does *every* insurance company in the US require it for men over 40 before issuing a life insurance policy. The insurance companies pay for the test, so if its truly an unnecessary expense (in terms of determining mortality), wouldn't they eliminate it?

Posted by: John M | Nov 3, 2007 10:28:13 AM

John M, you are an idiot. A patient's suitability for screening is determined by their doctor, not by harebrained blog comment "acid tests".

Posted by: lois | Nov 5, 2007 9:03:03 AM

Depending on my assumptions, I can reach one of two conclusions from Ezra's chart:

1) If I assume that English men get prostate cancer at the same rate as American men,

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