Ezra Klein wrote an interesting post Wednesday arguing that extending life through medical intervention is expensive and that tradeoffs and rationing have to be made. The only question, then, is how much value is placed on that extra unit of health care and who’s making the valuation.
The inverse of the American health care system is the British health care system. Where we are the priciest, they are the cheapest. We refuse to make any explicit decisions, instead denying care based on criteria that makes the denial the fault of the patient rather than the system. You don’t have enough money for the treatment. They make all their decisions explicit, relying on criteria that makes the denial the fault of the system’s judgments. We don’t think that treatment worth the cost. Their system gives patients someone to be angry at. Ours has no connection to value. Their system creates more blame, ours engenders more tragedy.
What’s at issue here is rationing. In 2006, adjusted for purchasing power, the United Kingdom spent $2,760 per person on health care. America spent $6,714. It’s a difference of almost $4,000 per person, spread across the population. That’s $4,000 that can go into wages, or schools, or defense, or luxury, or mortgage-backed securities. And there’s no evidence that Britain’s aggregate outcomes are noticeable worse. But they do say “no” a lot more than we do. Their system refuses to pay high prices for medical technologies and pharmaceuticals that it judges insufficiently effective. They’ve forced themselves to make choice, because they have something we don’t have: A global budget.
I never found time to respond to this but several others have. Andrew Sullivan has the most poignant retort:
One reason I’m a conservative is the British National Health Service. Until you have lived under socialism, it sounds like a great idea. It isn’t misery – although watching my parents go through the system lately has been nerve-wracking – but there is a basic assumption. The government collective decides everything. You, the individual patient, and you, the individual doctor, are the least of their concerns. I prefer freedom and the market to rationalism and the collective. That’s why I live here.
(It’s also, incidentally, a rejoinder to the hordes who question Sully’s right to call himself a “conservative.”) Steve Bainbridge agrees and wonders why Sully voted for Obama, since he’s much more likely to lead us in the direction of nationalized health care than McCain would have been. Ron Chusid, meanwhile, agrees in theory with Andrew but adds, “Pragmatically we cannot ignore these differences in spending, especially considering the large number of American who are uninsured or under-insured.”
Noah Pollack, though, questions the premise of similar outcomes in the US and UK. He cites David Gratzer, who in turn cites a Lancet Oncology study:
* The American five-year survival rate for prostate cancer is 99 percent, the European average is 78 percent, and the Scottish and Welsh rate is close to 71 percent. (English data were incomplete.)
* For the 16 different types of cancer examined in the study, American men have a five-year survival rate of 66 percent, compared with only 47 percent for European men. Among European countries, only Sweden has an overall survival rate for men of more than 60 percent.
* American women have a 63 percent chance of living at least five years after a cancer diagnosis, compared with 56 percent for European women. For women, only five European countries have an overall survival rate of more than 60 percent.
Ironically, Ezra has managed to engender a large cross-blog debate about the comparative merits of the US and UK systems despite his longstanding campaign to establish that as a canard. For example, his recent post THE CANADA/ENGLAND FALLACY correctly notes,
It’s natural to look to England. It’s just not all that useful. We will never have a situation in this country where you are not allowed to purchase your own care on the private market. It won’t happen, it’s not under consideration, and it’s not a plausible outcome of any plans being seriously examined. Conversely, something like France, where the government provides base insurance and the private market offers supplementary products, or Germany, where heavily-regulated non-profits compete with each other to offer coverage, is fairly likely.
While extremely dubious of further nationalizing our system, I agree that a UK-style system is incredibly unlikely to emerge here and we’re much more likely to have a public-private hybrid that simply leans ever more public. I’m not philosophically opposed to the idea, since health care isn’t a pure market (there’s little elasticity of demand, for one thing) and the current system is incredibly inefficient. But I do fear disencentivizing research and the provision of cutting edge resources and the general DMV-ization of health care.
UPDATE (Dave Schuler)
I’ve written a lot on this subject over the years but my observations are too long for the comments section and too intrusive to include in the update. I’ve put those observations, along with a substantial bibliography of my old posts on this subject, at The Glittering Eye.
Photo by Flickr user Erik K Veland under Creative Commons license.
