We're...Not Number One

Jon Cohn has a very good article comparing America's health care system to those of other lands. Two parts I want to highlight:

• On technology:

Look at Japan. It has universal health care. It also has more CT scanners and MRIs, per person, than the United States. It's true that the European countries tend to have less technology (although Germany and Switzerland appear to be comparable or at least very close.) But their citizens get more of something else relative to Americans: Face time with doctors and time in hospitals. Take France, for example. As New York University's Victor Rodwin has noted, on a per capita basis the French get more physician office visits and more drugs than their American counterparts. When a woman in France gives birth, she gets to stay in the hospital for an average of nearly five days--even if it's a perfectly normal delivery. In the United States, on average, a woman with normal labor and delivery gets to stay less than two.

• On the argument that Americans get better care prostate cancer care (and thus, by extension, better care generally. We've gone through this one at great length):

Another wrinkle is that the comparisons look a lot different in you look at populations as a whole, rather than just those diagnosed with the disease. Yes, an American diagnosed with prostate cancer is less likely to die than, say, a German diagnosed with prostate cancer. But Americans on the whole are no less likely to die of the disease than Germans on the whole--and the same is true for most of the other well-developed countries in Europe. In fact, the percentage of the population that dies from prostate cancer is remarkably consistent between the United States and the most advanced European nations.

So what's the explanation? One possibility is that aggressive screening in the United States turns up a lot of slow-growing tumors--cancers that would not have ultimately killed people had they been allowed to grow. This seems particularly plausible in the case of prostate cancer. Simply put, the U.S. cure rate may look better than the rest of the world's because we're curing a lot of cancers that don't need to be cured.

No, we can't be sure about this. It's possible that, even accounting for such over-treatment, the United States still has better treatment for breast and prostate cancer. But, even if that were true, it's hard to read the data as indictment of universal health care when the U.S. survival rate on other ailments isn't so superior. The Swedes are more likely than Americans to survive a diagnosis of cervical, ovarian, or skin cancer; the French are more likely to survive stomach cancer, Hodgkins disease, and non-Hodgkins lymphoma. Aussies, Brits, and Canadians do better on liver and kidney transplants.

And all the usual caveats apply: They do it for less money, while providing universal coverage, etc, etc. We're spending twice as much as anyone else, leaving 45 million of our countrymen uninsured, and getting outcomes that are comparable or a bit worse. Moreover, as Jon argues in the first bit I quoted, we lose quite a bit in the availability of basic care and the amount of time we can spend with practitioners, which I can't imagine is a good thing. Indeed, America's got wonderfully advanced trauma care, but we're much worse at the preventative, basic stuff. And this is a question of medical culture. It's telling that hospital emergency rooms, where the most severe and urgent cases are treated with the most violent interventions, can't turn away the poor, while general practitioners, who can catch illnesses early and intervene cheaply, can send the destitute packing.