Health Care Like The Europeans Do It

The New Republic: France And Germany Are Prime Examples Of Successful Universal Health Care

(The New Republic)  This column was written by Jonathan Cohn.

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Depending on where you get your political commentary, you may have heard that John Edwards is a bad husband or father for sticking with his presidential campaign even though his wife, Elizabeth, was recently diagnosed with stage four breast cancer. But did you know that he is also a hypocrite — or, at least, a fool? That's what conservative critics of his health insurance plan have been implying. "One hesitates to intrude upon a personal tragedy to make a political point," Michael Tanner, of the Cato Institute, wrote recently. "While one sympathizes with Elizabeth Edwards and wishes her well, it's important to note that the national health care system her husband has taken this opportunity to propose would be disastrous to thousands of Americans who suffer from cancer and other diseases."

Though Elizabeth Edwards' diagnosis has made it newsworthy again, this argument — that countries with universal coverage ration care and limit investment in new medical technology at the expense of seriously ill patients who require the most advanced treatments — has been around for a while. Tanner made the same point in a 2005 book called "Healthy Competition," which he co-wrote with his Cato colleague Michael Cannon. David Gratzer, a physician and health care policy expert at the Manhattan Institute, did the same in his 2006 book, "The Cure." Going back a bit farther, Harry Truman's opponents warned of European-style rationing when he proposed creating universal coverage in the 1940s; Bill Clinton's opponents did the same in the 1990s.

It's a potent argument politically. Americans certainly don't like the idea of losing their health insurance and facing medical bills on their own — a problem universal plans like Edwards' would overcome. But they're also spooked by the prospect that they might not be able to get the best, most advanced life-saving care if faced with a deadly disease. That's particularly true for more affluent Americans, for whom the threat of losing insurance coverage seems remote — and whose ample financial resources (not to mention personal connections) give them access to this country's top doctors and hospitals.

But is it actually true that universal coverage results in worse care? That's a very different story from the one that conservatives tell.

Let's start with what we know for sure. Relative to other highly advanced countries, the United States lags well behind the leaders when it comes to infant mortality, overall life expectancy, and life expectancy at 65. In fact, on all three, the United States is actually lower than the average for the nations of the Organization of Economic Cooperation and Development. If you live in Canada, Japan, or virtually any part of Western Europe or Scandinavia, then you're expected to live longer than if you do in the United States.

Critics argue that measuring infant mortality and life expectancy is too crude, since whether a newborn dies or how long somebody ends up living may have as much to do with outside conditions like poverty, environment, and lifestyle as they do with the quality of medical care. And while it's a bit unfair to treat these entirely separate from health insurance — universal coverage helps reduce poverty, among other things — the measures are crude. That's why the scholars who specialize in comparing international health care systems prefer to look at some more finely tuned calculations: "potential years of life lost" or "disability adjusted life years." The latter is the preferred measure of Gerard Anderson, a professor at the Johns Hopkins School of Public Health and a leading expert on international comparisons. But, as he's noted many times, on these measures, too, the United States is decidedly mediocre compared to Japan and the more advanced countries in Europe.

Conservatives insist that even these, more finely adjusted measures still can't adequately account for outside influences like poverty or environment. As such, they say, the only way to really grasp why the U.S system is better than those abroad, you need to look at health care-specific factors — like the amount of high-tech technology here versus there. In universal health care systems, the government inevitably exercises more control over health care spending. This is a big reason why all the other systems cost less — and, if you believe the critics, why people in those other systems get less.

It sounds perfectly reasonable in theory. But the facts don't back it up. 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.

Why the difference? The big reason is that private insurance in this country has squeezed inpatient time to the bare minimum, while universal coverage in France has preserved longer periods for convalescence — just as it has in other countries. The Germans get almost as much time as the French.

Truth be told, if there's an objection to relying on this sort of data, it's that they measure inputs and not outputs. Who's to say that more technology — or more days in the hospital — really does amount to better medical care? A lot of experts would argue that sometimes the opposite is true. And they would have a point.

That leaves one place to look: The results of people who actually get sick. This is where the conservative argument about American superiority seems most persuasive — because, in a few cases, it actually has some merit. Cannon, Gratzer, Tanner, and others have all seized on the survival rates for cancers — particularly breast cancer and prostate cancer. In those two cases, Americans diagnosed with those diseases are significantly more likely to live than Europeans diagnosed with them.

But before leaping to the conclusion that this proves the overall superiority of American health care — and, by extension, the inferiority of universal coverage — you have to consider a slew of caveats. The first is that the "European" average includes the entire continent — not just the more advanced systems in Scandinavia and Western Europe, but also the more hidebound ones in Eastern and (to some extent) Southern Europe. The gap closes if you limit the comparison to the most advanced countries.

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. (You can see this dichotomy vividly in a chart, produced here by The American Prospect's Ezra Klein.)

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.

All of this comes with an important cautionary note: Measuring the outcomes of medical care is an imperfect science at best, in all countries. (Plus the measurement standards themselves are different sometimes.) It's difficult to make a ironclad case that any one system is better than another. But the fact that countries with universal health care routinely outperform the United States on many fronts — and that, overall, their citizens end up healthier — ought to be enough, at least, to discredit the argument that universal care leads to worse care.

And that, in turn, ought to tip the scales of debate, since not even conservatives dispute the one clear advantage other countries have over us: You don't see their citizens choosing between prescriptions and groceries, or declaring bankruptcy, because of medical bills. As John Edwards put it when he announced his health care plan, "It doesn't have to be that way." Sounds like he knows what he's talking about after all.

[sy2502]

ajaxrose1 you hit the nail on the head! Also consider that in some European countries you pay up to 40% in taxes, and you still get such crappy universal medical care, that you have to cough up more money to go to private clinics. I am not saying that the American system as it is right now is perfect, but universal care would make it many times worse.

[nathanealy]

I glad to see we are willing to give up freedom for security and privacy for low cost Viagra.

[noaanhc]

For the United States,the richest and most powerful nation on Earth,to deny her citizens universial heath care coverage is a complete national disgrace.

[sjc_1]

Quite the opposite, the latest trend is for Americans to go to other countries for health care. Some surgeries cost 1/10th as much in other countries and the quality of care is on par. They did a news story about a lady that got a heart operation that would have cost $200,000 here for $20,000 in another country and the package included a 2 week vacation for her and her daughter. How is that for global competition?

[ajaxrose1]

IF the health care in other countries is so great then why do so many come to the U.S. for treatment? BECAUSE THEY CAN'T GET THE SAME CARE IN THEIR OWN COUNTRY! Americans also don't like being told what they HAVE to do and gripe enough about HMO's. Imagine having your zip code decide which doctor you saw? Nevermind that this doctor isn't someone you don't like, you're stuck because this is who you live closest to. Americans don't like the taxes they pay NOW. Check into the tax rates for these "advanced" Socialist countries and if it's SO acceptable, then MOVE there.

[roach9703]

From what I have seen from neighbors and friends, the disability and health care is increasingly NOT working in America.
With one neighbor, the health care premium eats up more that a quarter of her paycheck, and that is just for that one individual?
A person I know in New England was cheated out of disability benefits with little recourse.
I had the experience of my wife nearely being denied benefits in the early 1980s from a medical emergency.
As a person who has experience in health care collections, the layers of bureaucracy are truely amazing. There is a lack of initative in hospitals and insurance companies to develop better cost accounting and reimbursment methods.
It is not a tolerable situation that so many American have their credit ruined and made bankrupt by healcare costs.
However, central control does bring the risk of great tyranny.
There is an approach called the Conservative Approach to Health Care.

[cathaleen]

First these pinheads have to understand that the size of our country is ten times the size of the European socialist countries. We are not socialists, we are capitalists. That's why people in this country make much higher salaries and work longer hours than our European cousins.
Now, the only way for universal healthcare tp work in this country is if it is done by each state. Then someone has to explain to the doctors why they no longer will be wealthy.

[sy2502]

I think people should try to live in Europe for a bit (where I was born and raised) and get an idea of how "wonderful" health care is there, then I can guarantee you they would understand how badly things really work there!
If you think that universal health care eliminates layers of bureaucracy, you are CRAZY! There is way less bureaucracy here. You have to book something as simple as a blood test weeks in advance while here I just walk in and have it done. You have limited or no choice in doctors and hospitals, you have to go to the one assigned to your district, whether it is good or bad (often bad). If you want any decent medical care you still end up going to private doctors and private clinics, except that since your universal health care plan doesn't cover private medical care, you have to pay it 100% through your nose.
So people, it is easy to sit on your side of the fence and whine on how green the grass is on the other side. If you actually experienced it first hand, you would run away screaming.

[hangelle]

lilvinnyb - ignorance is bliss, isn't it?!

[bettyas-2009]

I am type 2 diabetic. My insurance will not pay for diabetes training or testing supplies. They will pay for the operation to remove my toes when I loose them to complications from diabetes.

Can someone explain the logic in this?

If I loose this insurance I won't be able to get new coverage either.

[lilvinnyb]

So lets see, the same people clamoring for health care run by the government are the same people who complain about the Beauracy exposed by Katrina and Walter Reed Medical. Imagine the beauracy created by universal health care....OUCH!

As for "big Pharma", why not thank them for the millions of drugs they develop every day to make our lives easier and our pains more bearable.

As for cost. Canadians pay about 40% in income tax to pay for their universal health care and 15% sales tax. As far as im concerned, they can have it.

As for quality. Ive love to see where someone got those rankings from. As far as I see in the news, people are constantly coming to the states for operations, life saving medical treatments, etc. Many things we would not have if the government was running our health care system.

You want good health care...educate yourself, strap up your boots, get a good job that has coverage and stop looking to the government for all your needs.

[sjc_1]

I have heard that Medicare is administered for less than 2% overhead and private health insurance takes more than 20% of the revenue. If that is the case, let's let the private and public sectors compete. Let people chose private insurance or public and see who provides the most for the least.

[sjc_1]

The advancement argument is false. The U.S. pays much more for health care, yet ranks down the list in quality of health care. If the market system is suppose to work, you would think it would have by now.

[condumism]

the USA: only first world nation of earth without universal health care. Thanks to the self-centered scum of America, Repiglicons, the USA is headed for 3rd world status by 2020. The USA can't compete in the global economy without universal health care. Cost of universal health care in Europe and Canada: 8% of GDP, in the USA: 16% of GDP and expected to be 25% by 2020. Here's a fact about Baby boomer Rethuglicon's: most are planning to retire outside the USA, ie: in Mexico, which does indeed have universal health care (although substandard). But while thse self-centered baby boomer Rethuglicons are in teh USA, leaching off of American society, they'll do everything that they can to support the USA's failed health care system. HOW HYPOCRITICAL can any one group get?

[skyk-2009]

Buy the best health insurance you can afford and pay for it yourself, you'll be glad you did. Avoid the huge tax burdon of universal health care. The US is too big of a country to manage something like Universal health care.
Posted by bellaL at 11:45 PM : Apr 10, 2007
+ report abuse

Now this is a typical Con, defeatest, attitude. We not only can but should trash the VERY expensive system we have and I know WE, as American's, can at LEAST do as good a job as our friends to the North of having and keeping Health Care for all our people.

[skyk-2009]

am self employed. I pay 7000 a year for catastrophic coverage only. You cant tell me the tax burden would be much more than that
Posted by ainttaken at 11:49 PM : Apr 10, 2007

I think that's the point there Sparky. We have a system so bad, so costly, that people can't afford it. When there are SO MANY who can't afford coverage, who can't afford any normal care, the cost on those of us who can manage to get it is beyond our means. If everyone remembers when we had strong Unions and Health Care came with the job, the cost of that wasn't important at all. When we allowed the Fascist to start busting those unions then those who were ONCE afraid of them, just dropped coverage and the downward spiral started.

[drinuk]

All of the afore mentioned problems will not be solved until Big Pharma is put firmly in their place. Until the servants of the people, the FDA are truly free of their influence and ALL politicians begin looking after the people and not Big Pharma.
Whether on the National Health Scheme in the UK or private insured health in America, we are all being shafted by the Pharmaceuticals, who in turn finance the FDA and many sections of Government. They are the health industry Mafia, they are a worldwide corrupt organisation whose only goal is money and power. They are supported by some of the most powerful individuals in the world and their remit is certainly not curing the sick.
The tenticles of Big Pharma are everywhere, from the President and our Prime Minister right down to your local Doctor. They are liars and cheats, caring little for you or your family. They actively supress natural un-patentable and cheap cures in favour of their evil poisons and kill millions of people in doing so.
Their time must end soon, it has got to stop. We could all have reasonably inexpensive health care but for their wicked rape. They have made cancer a very successful business whilst the figures actually get worse by the year.

[sonofapundit]

One big difference if we went national: there wouldn't be a middleman (insurance companies) sitting around making half the money. I.e., there would be a PROFOUND discount attributable strictly to eliminating the horrendously greedy $hithole healthcare insurance industry. Notice they're the ones with the money, and therefore, the ones doing all the talking... leading you to believe that national healthcare would be a bad thing. Here in the US, you have to FIGHT for good healthcare (that is, threaten to sue), and not all people fight equally well... so, good fighters get good care, and bad bad, and either way, insurance rips you off. Meanwhile, the uninsured get NO care. Screw that. And you fools saying we're too big of a country... what we have is too much border space with Mexico, and too many supply-siders who want them here to wait tables (while regular joes continue to pay for their housing, food, and healthcare via unpaid bills). Secure the borders, end unnecessary wars and policing, and fund education and health before WE'RE Mexico. We are the sickest people in the first world, and as long as we waste half our healthcare money keeping insurance company leaches fed, we'll continue to be.

[bellal-2009]

It would be interesting to see what the actual cost would be. It has to be astronomical. What does Social Security cost to administer, and this would be much larger.

[bellal-2009]

Buy the best health insurance you can afford and pay for it yourself, you'll be glad you did. Avoid the huge tax burdon of universal health care. The US is too big of a country to manage something like Universal health care.