Tuesday, November 20, 2012

Health economics update

Russ Roberts did a podcast with me in his "EconTalk" series, on my "After the ACA'' article. Russ also put together a really nice list of readings with the podcast, at the same link.

I also found this very informative editorial "What the world doesn't know about health care in America" by Scott Atlas. It goes a good way to answering the persistent "What about how great health care is in Europe" comments. Some choice quotes:
Affirming 2005’s Chaoulli v. Quebec, in which [Canadian] Supreme Court justices famously concluded “access to a waiting list is not access to health care,” [my emphasis] countless studies document grave consequences from prolonged waits...
I love this little quote, because the deliberate confusion of "insurance" with "access" has long bugged me about the US debate.

Lots and lots of things are dysfunctional about US health care, but not the long waits that others endure
...“waiting lists are not a feature in the United States,” as stated in a 2007 study and separately underscored by the OECD .
They're talking months here, not 6 hours in the ER.
Americans would be stunned to hear the reality of nationalized insurance:

• In its latest “care guarantee,” Sweden found it necessary to stipulate that patients must be able to see a doctor within seven days; patients should not wait more than 90 days to see a specialist; and treatment should be scheduled within 90 days…six months from presentation;...

• England’s 2010 “NHS Constitution” declared that no patient should wait beyond 18 weeks for treatment (after GP referral). Even given this long leash, the number of patients not being treated within that time soared by 43% to almost 30,000 in January.
How about all those wellness visits, the idea that under socialized medicine, people will get lots of cost-effective preventive care so they don't  wind up at the ER with something expensive? It turns out that's better in the US despite our chaotic system:
...treatment of diagnosed high blood pressure, the focus of preventing heart failure and stroke, was highest in the US (53%), lowest in England (25%), then Sweden and Germany (26%), Spain (27%), Italy (32%), and Canada (36%). In 2010, drug treatment was higher in the US than all European countries, including Austria, Denmark, France, Germany, Greece, Italy, Netherlands, Spain, Sweden, and Switzerland. In 2011, nearly 70% of Britons with known hypertension were left untreated.
And when you do get something serious?
Waits for diagnosis and treatment of heart disease, the leading cause of death in the US and Europe, plague nationalized health systems. OECD reported delays of several weeks to months for treatment in Australia, Canada, Finland, England, Norway, and Spain – not including waiting for specialist appointments. In 2008-2009, the average wait for CABG (coronary artery bypass) in the UK was 57 days. Swedes waited a median of 55 days, even though 75% were “imperative” or “urgent.” Canada’s heart surgery patients wait more than 10 weeks after seeing the doctor, and two months for CABG even after cardiologist appointments. 
The obvious point: Of course, under the ACA, many new patients and "cost control" price caps, we are surely heading in the same direction: rationing by wait time.

The less obvious point: Remember all the critics I cited in "After the ACA'' painting the picture that sick people need treatment now, and can't possibly shop? That really is a misleading picture.

The bottom line
..gradually, Europeans are circumventing their systems. Half a million Swedes now use private insurance, up from 100,000 a decade ago. Almost two-thirds of Brits earning more than $78,700 have done the same. But what might really surprise those who assert the excellence of nationalized insurance systems is that throughout Europe, from Britain to Denmark to Sweden, when faced with their inability to deliver timely access, the government’s solution is increasingly to enable access to private health care.
I don't know enough about European "private health insurance" to know how it works. Individual, private health insurance is so screwed up in this country that it's not clear we will have this option.  And, the point of After the ACA, paying with your own money doesn't do much good if there is not a competitive market supplying health services.