I've been wondering about a historical question lately and I would appreciate your feedback.
How did the U.S. health care system — in terms of outcomes — compare to other countries before the mid-1960s Recall that Germany and New Zealand had some version of universal coverage well before WWII and of course many countries adopted universal or near-universal coverage after WWII. In terms of crude "bang for the buck" comparisons — dollars spent relative to health care outcomes — how did the U.S. compare? At that time we didn't even have Medicare or Medicaid.
You should probably consider the effects of WWII in making any comparison between life expectancies, etc in the US vs European countries. Those growing up in war-torn countries would be more likely to suffer malnutrition and disrupted childhoods that could have longstanding health effects. Americans didn’t have the same experience. So I think a “crude” comparison may not present any useful information without controlling for those differences.
@#1: How about Sweden or Switzerland?
tyler: “dollars spent relative to health care outcomes”
What do you mean by “health care outcomes”? Surely you do not mean life expectancy and infant mortality, do you? After all, lifestyle choices and genetics likely have more influence on life expectancy than does health care. Infant mortality statistics are not mneasured the same way around the globe today. It seems unlikely that statistic would have been more reliable 50 years ago.
Perhaps, by health care outcomes, you mean more relevant statistics such as surgery infection rates and survival rates after surgery. Even controversial health care measures, such as hospital readmission rates or hospitality mortality rates, would still be more relevant than the much too broad life expectancy statistic. It seems unlikely, though, that we could find reliable and consistent health care outcomes measures from the pre-computer days of health care.
http://www.nationmaster.com/graph/hea_lif_exp_at_bir_tot_yea-life-expectancy-birth-total-years&date=1960
Norway Sweden and the Netherlands had a life expectancy over 73 years in 1960 and in the US and Germany it was about 69 years.
Were any of the funds from the Marshall Plan applied to health care? If so, how much? Did any of it result in comprehensive coverage where before there was more limited coverage?
Tyler, let me help you by anticipating where this line of reasoning leads…
What you will eventually have to tackle is defining which health care outcome is relevant to “health care system superiority.” (Quotations invoked to indicate an absence of jargon.) From there, you will reason that an effective health care system must divert its dollars toward activities that address those specific outcomes. So which outcomes will we fund?
1) Longevity or QALYs? Is it more important to live long at a lower quality of life or die sooner but at a high standard of health?
2) High level or personalized care, or high volume of patients served? Is it better to exclude some patients so that those who enter the system can enjoy a reasonable standard of care?
3) Lack of repeat visits? Is it better to treat patients until they are definitely healthy, or is it better to treat them “adequately enough” to avoid a high cost/patient ratio? (Important sub-topics: what is the long-term effect of each policy? what about patients who voluntarily forego care as the result of disillusionment/inadequate treatment?)
4) Clinical benchmarks or disease eradication? Again I bring up high cholesterol – Should we be prescribing statins to all patients with high cholesterol when there is little scientific evidence that lowering cholesterol avoids cardiac events?
These kinds of questions are what health economists outside the USA are constantly mired in. There is no fair decision here. You either let the market function however ineffectively, or you become the Health Czar and dictate for all human beings how you personally think they should be treated.
It’s a trap.
Lonely Libertarian: “If prostate cancer patients are living five years longer, but we are discovering they have cancer 3-5 years sooner the net impact of improved treatment is far less significant”
According to the Department of Urology at Mayo Clinic in Rochester, it was the introduction of the prostate-specific antigen (PSA) test in the 1980s which allowed detection of early stages of prostate cancer. Detection of prostate cancer in the early stages sharply reduced the the risk of cancer spreading to other organs:
“In 1987, only 42 percent of patients had cancer confined to the organ at the time of surgery while in 1998 almost 80 percent of patients had cancer confined to the organ at the time of surgery.”
If the PSA test was effective at detecting life-threatening cancer in early stages, then we should credit the U.S. medical research industry generally, and Dr. Thomas Stamey of Staford in particular, with developing the test which enabled early detection. However, Dr. Stamey has now determined, after 20 years of analysis, that the PSA test may not be as effective as once believed in detecting life-threatening cancer.
Should we consider the expenses of PSA testing to be wasteful spending over the past two decades? Some have argued that such research and higher spending on disease of the elderly resulted from the Medicare guarantee of reimbursement to treatment of the elderly.
JSK: “According to your metric a country like North Korea would have the best health care in the world: presumeably a tiny elite of higher party members receives the best surgery money can buy, while 99,9% of the population goes without.”
First, I do not believe your assertion about North Korea to be true. Though their public health care system is near collapse, they do apparently attempt to treat far more than 0.1% of the population.
Let’s assume, for the sake of argument, that your assertions were correct. Then we could correctly claim that the North Korean health care system for the party elite is the most effective in the world – at performing its mission.
The problem with comparing health care outcomes – as Tyler requested that we do – is that the only appropriate measures would be those which are consistent with the mission of the entities being measured. The U.S. health care system – more accurately, the set of U.S. health care providers – has never been tasked with increasing the life expectancy of Americans, nor given the power to do so. So it is completely inappropriate to measure the effectivenes of the set of U.S. health care providers at increasing life expectancy.
U.S. doctors and hospitals have been tasked with:
- diagnosing the illnesses of patients who seek care;
- prescribing the appropriate treament for those illnesses;
- delivering the prescribed treatments;
- reducing the rate of infection while doing so;
- reducing the rate of readmission after treatment; and
- increasing the survival rate of those who received treatment.
Measuring the effectiveness of doctors and hospitals at fulfilling those roles is appropriate, but much more difficult.
wow, what a hard question!
Maybe a more basic & useful comparison should be diet, pre and post WWII in other countries. It’s just easier to understand for me but still valuable because diet and environment influence so much of what is called health care. Just measure the height of everyone on the Korean peninsula above and below the 38th parallel to get an idea of what diet, exercise, and the chance to jog around where you like to (or even play with a Nintendo Wii!!).
Or maybe just simplify it to milk. Cows eat what you feed them and then we eat what we want from them. How well do we measure milk consumption though? For example, if its just calories in calories out, we could look at Olympic records to see who has the best health care policy and how that has changed over time.
I mean, just replace the word countries with states, and it’s just as impossible to understand or make policy around, let alone discuss objectively. And perhaps even more prone to political games than other countries (I say this because the USFG gives out so much money for food stamps and farmers).
But still a neat question to think about.
JD
I may have tried to make something simple hard – and if so my bad…
The heart of our difference can be found in your statement…
“the increase in survival rates for prostate cancer is a direct result of health care research spending”
I see no causal relationship where you seem to see one – correlation yes – but no proof of a causal link.
As for the PSA test – it was “effective” because it was part of a regular exam – which often includes the dreaded digital probe[DRE] – again attributing early detection to PSA test is not possible if other variables are also changing.
And this summarizes my concern better than I have I think…
“Because of an elevated PSA level, some men may be diagnosed with a prostate cancer that they would have never even known about at all. It would never have caused any symptoms or lead to their death. But they may still be treated with either surgery or radiation, either because the doctor can’t be sure how aggressive the cancer might be, or because the men are uncomfortable not having any treatment. These treatments can have side effects that seriously affect a man’s quality of life”
Talk about adverse selection!
For what it’s worth, Gapminder life expectancy vs income over time. I have focused on English speaking countries for comparison. If you mouse over a years data point, it will trace out the history for that country. Australia and New Zealand (red) start out behind, but make rapid progress after 1880 and by the 1930s are above the others and stay that way. Canada makes some early but less dramatic progress still remains ahead of the US. While the UK usually lagged behind the US until post WWII when even it surpassed the US. The US is definitely the laggard of English speaking countries post 1930s though it did not start out that way. It does appear Medicare/Medicaid definitely improved the situation since longevity was beginning to stagnate in the US before it.
But if color tv extended life, we should certainly be ahead of everyone! Arguments are disputable, facts are not. If non treatment was superior than the rate of life extension should have increased before medicare. Bad theories and twisted arguments are no substitute for reality.
lonely libertarian… watchful waiting still requires doctor visits, diagnostics, etc. watchful waiting still costs money. maybe even more than a routine prostate removal on the aggragate. your anecdote does not address the original question about outcomes.
@Dewey:
The problem with comparing health care outcomes – as Tyler requested that we do – is that the only appropriate measures would be those which are consistent with the mission of the entities being measured.
U.S. doctors and hospitals have been tasked with:
Alright, i stick to my previous point. You’re defining away the issue, almost making it a tautology. With your line of reasoning you can turn economic policy under Putin, (or even economic policy under Mugabe!), Chinese environmental policy or the reign of Charles Taylor of Liberia into uncompromising successes: given their mission (namely enrichment of a tiny group) the above do or did extremely well. But my follow question is: so *you* get to decide what the “mission” is of the American health care system?
Moreover, im still waiting for a form of evidence on ethnicity and health outcomes.
If you accept life extension as the aim of healthcare and that spending is its driver, then a 1:1 cost benefit ratio makes us indentured servants to healthcare as all the economic benefit is consumed by the cost. If you assume what others spend keep up with longevity but not extend it and only the 5% excess gdp spent here does that then there would be an 80% loss on healthcare spending. If you assume spending is irrelevant, we are flushing 5% gdp down the drain. Either way, it should be subject to a hefty pigou tax rather than expanded.
Can’t resist…
1. When those who play sports and exercise need hip or knee replacements we expect our insurers to cover them
2. We are not sure what is really “healthy” eating – but that has not stopped us from urging at various points in our history people to avoid butter, red wine, caffeine, salt and sugar.
3a. The net cost of tobacco abuse fails to include the benefit we get from taxing tobacco users at punitive rates to fund a variety of programs – and ignores the fact that a significant percentage of “abusers” live long enough to die from natural causes – they die cancer free but over-taxed.
3b. While numerous studies have found a benefit from consuming moderate quantities of alcohol we refuse to force everyone to drink two glasses of red wine each day.
3c. We spend enormous amounts of money on the war on drugs – and continue to lose. The best we have been able to do is fill our prisons with a disproportionate share of minorities who abuse crack cocaine.
4. At least you did not go for the gun control angle – thought you would.
5. We continue to believe that a risk free life is possible and preferable to a rich and rewarding journey that involves a range of experience – some safer than others.
Tyler Cowen asks: “How did the U.S. health care system — in terms of outcomes — compare to other countries before the mid-1960′s.
Which “health care system” do you mean?
There is the Center for Disease Control system tasked with control of infectious diseases. There is the FDA tasked with the quality of foods and drugs. You probably mean the medical care system of hospitals, nurses and doctors tasked with “sick care” some private, some public, e.g. The Veterans Administration, county hospitals in some states, some blend public and private, e.g. university hospitals with indigent care clinics etc. You may also be referring to one of the several “sick care” financing systems ranging from self payment, private insurance, employer provided insurance to government provided insurance.
What outcomes do you have in mind?
Life expectancy, survival after diagnosis for any one of many diseases, patient satisfaction, waiting time for elective surgery, availability of primary care, etc.
These two questions will need to be answered before proceeding to bang for the buck comparisons. Much of the public debate is a mess because the “health care system” is many different things.
JSK You may be able to answer your questions about race and changes in mortality over time here:
http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdf
Table 2 shows percent surviving by age in 2004 for white females (best), white males, black females (tied) and black males (worst).
or here:
http://www.cdc.gov/nchs/data/hus/hus07.pdf
If life expectancy is your proxy for “health care” a multinational set of life tables for many different years is here:
http://www.lifetable.de/cgi-bin/datamap.plx
@Mark:
Table 2 shows percent surviving by age in 2004 for white females (best), white males, black females (tied) and black males (worst).
Are there controls for background variables? I’m aware of the simple correlations. So that’s why im asking for a *medical* doctor: is their a *physiological* reason for blacks dying earlier than whites, or is it just a function of their higher poverty rates?
@Dewey: For me your reasoning amounts to little more than “Because I say so” and i cant take it seriously. I guess the economics profession in general, Tyler and a very very minor economist as myself start from a utilitarian philosophy of the good (greatest happiness for the greatest number of people), you appear to adhear to a libertarianesque quasi-religious principle of “thing’s functions and purposes are set in stone”.
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