Tyler Cowen pretends he is a Democrat

If I were a Democrat…

First, I would not cite evidence about how Western European countries spend less on health and are healthier than U.S. citizens.  This data set, if you take it seriously, also implies that the marginal product of more health care, adjusting for income and a few other variables, is zero.  Expanding health care would not be important.  Now I believe this is an incorrect conclusion, but that is what shows up in this data.  We should not invoke this data selectively.

Second, I would recognize that American policy generally works (or doesn’t work) by building upon existing institutions.  The most likely form of national health care — for better or worse — would extend a version of Medicare to more people.  This would not lower health care costs, whether in gross or quality-adjusted terms.  Keep in mind that negotiating price reductions does not per se lower real resource costs at all. 

I would disaggregate health care systems and see where we could do the most good:

1. Step up R&D subsidies through the NIH and our university system, both high quality institutions.  Their autonomy and micro-fiefdoms provide a good framework for risk-taking and innovation.  The returns to medical R&D are extremely high.  Furthermore the case for market failure, based on the inability to capture the full social gains from a new idea, is simple. 

2. Redo the Medicare drug bill so that people can understand it (even I can’t, nor does my mother), and so more people benefit.  If need be, we can do this in budget-neutral fashion.  The Bush plan is a mess.

3. Invest in local public health systems.  Preventive care is important, especially for the poor.  Price can be an obstacle but often the relevant constraints are behavioral in nature.  Public health care systems should be easy and inviting, and they have to become part of life routines.  Government can be part of the solution.  Strong local public health care also will improve surveillance and later surge capacity if a pandemic comes along; this added benefit is significant.

4. Borrow a page from the libertarian litany about the FDA.

5. Institute prizes for successful vaccines.  We have been discouraging vaccine production when we should be encouraging it; Michael Kremer has some intriguing proposals.

All those options are doable.  All would save lives.  None are fiscal disasters.  They offer something for both rich and poor.  They lay out a positive and constructive role for government, while keeping room for the private sector.  None raise the prospect of excess bureaucracy or discourage innovation.  None rest on the questionable belief that government as single supplier or payer would improve efficiency.  And they are all areas where the Republicans are dropping the ball.

I would cut talk of national health insurance.  I would cease obsessing over the number of "40 million uninsured," however good a debating point it may be.  Many of these people are either linked to immigration or get decent medical coverage in any case.  I would admit that we cannot take care of everyone and that we face tough trade-offs.

Hmmm…these counterfactuals are fun.  What should I try next?  Pretending I am a Republican?  But for now, it is back to normal life…and so we return to your regularly scheduled programming.  But comments are open, in case Kevin Drum’s readers wish to pretend they are libertarians…

Comments

Fascinating. Why, do you think, have Republicans not chewed on these sorts of ideas (I am a rather reluctant Democrat myself and concede the intellectual bankruptcy of the party at this time)? Has incumbency turned them into overcautious softies? Have the people on Capitol Hill and in the think tanks, whose job it is to bat around ideas, turned over too much of the thinking to the White House? Are insurance companies, drug companies, etc, who give so much money to campaigns, too invested in the current system? I would think the political appeal of a national candidate/party that could offer some new (and relatively inexpensive) ideas on health care reform would be enormous and irresistible.

TC writes:

"First, I would not cite evidence about how Western European countries spend less on health and are healthier than U.S. citizens. This data set, if you take it seriously, also implies that the marginal product of more health care, adjusting for income and a few other variables, is zero."

1) The question is not the marginal product of "more health care" but the marginal product of more spending in the health care system, however it happens to be constituted. It should not be surprising if more spending on administration has zero health care value.

2) Stepping past that distinction, it is clear that the marginal product of more health care differs based on, among other things, how much a person is already spending on health care. The marginal value of $1000 in health care to someone who currently has no resources to spend on health care is quite large. The marginal value of $1000 in additional health care to someone who is already consuming lots of health care resources may be near zero.

Sorry. We true liberals and compassionate progressives can't pretned to be libertarian and Evil. We believe in government control for the greater good, not people doing their own thing (which is Evil).

Well, I'm glad you aren't a Democrat. And I'm REALLY glad you weren't a Democrat using bad economic theory to kill the New Deal.

1) is independantly a good idea, but it is not itself a cure for health care problems anymore than spending money on Pharma r&d was our prescription drug benefit plan.

2) The medicare drug bill needs to be scrapped and rewritten, but, once again, you're thinking too small and only slightly on topic. When liberals scream universal health care, hint, hint, they're talking about the UNINSURED.

3) Investing in local public health systems is a dubious idea. First of all, its not a permanent idea. If you invest in public health systems, Republicans will use their first opportunity to uninvest in them at no cost. Second of all, its once again throwing a pebble at an invading army in terms of adequate response. Third of all, it won't work for both federalist reasons (the federal government is bad at directing local institutions, and local institutions are bad at using grant money effectively when it is bestowed upon them without asking). Fourth of all, the amount of investment needed to make these things viable alternatives to private medicine is going to be significantly less politically feasible than UHC. Fifth of all, the amount of investment needed to make these things viable alterantives to private medicine is bad policy given we could just spend the money copying the very effective policies of (non-British) Western Europe (and Canada, too!).

4) is silly and not worth discussing. Kowtowing to the GOP based on an underlying theory of government that we don't believe in is not serious when it comes from Lieberman. When it comes from a REPUBLICAN (oh wait, a "liberterian"), its a joke, right?

5) "Institute prizes for successful vaccines". Vaccinations are great, and we don't need to resort to drugs to direct NHS and University money towards this goal. Except for AIDS and cancer, however, vaccinations aren't going to do much to solve the uninsured/cost problem, particularly given that the uninsured aren't going to GET these vaccinations in the first place . . . once again, a pebble at a rock problem.

"I would admit that we cannot take care of everyone and that we face tough trade-offs."

NO. WE. DO. NOT. YES. WE. CAN.

Don't you get it? Economics, as a predictive science, is a huuuuuuuuuuuuuuuuge failure. It always has been. This is hardly surprising, since the very basis of economics is based on flawed premises about human behavior and "utility". That being said, Canada and Western Europe's systems didn't spring out of nowhere, and they're not exactly mystical concepts that can't be replicated in the United States. We can insure everyone, get better results, and CUT TAXES DOING IT (sure, there will be a premium paid to the government, but this premium will be smaller than the premiums people currently pay, giving them more "income". Overall costs going to the health care delivery system should drop by a third, which, as you know, is a TON OF MONEY). I thought liberterians were AGAINST TAXES.

And in the previous post you point out that Canada, North Korea, and Cuba have the world's only "single payer" system. While this ignores the ease one can transfer to single payer and then, through cost cutting measures, to a French or Japanese system, it might also be useful to point out that CUBA HAS A SYSTEM WITH RESULTS COMPARABLE TO OURS. Which isn't really all that helpful to my argument. Until you realize THEY SPEND LESS THAN ONE FIFTH OF THE COST, AND LESS THAN HALF THE COST IN GOVERNMENT EXPENDITURES ALONE.

That this is "not politically feasible" is:

1) Because of people like you who should be ashamed of yourself and know better, who enable the lobbyists and the red-baiters in order to preserve their preconceived notions about classical economics.

2) No more true than the idea that gay marriage was infeasible in 1980, or that the elimination of the estate tax was infeasible in 1970, or that social security, medicare, and medicaid were infeasible in 1925. Political reality is not in stasis, and the Democrats (who are no longer the majority party) will not succeed anyway unless they can use persuasion to get the population to move with them, rather than "adjust" to form majority coalitions that no longer exist for them anyway.

Hmm...

Suppose I buy all my groceries at a convenience store, and pay $100 a week for them. My neighbor buys the same bundle of groceries every week at a supermarket, and pays only $80 for them.

Would this data set imply that the marginal product of my spending on groceries is zero?

Maybe in some hyper-technical sense, but not in any meaningful way. It implies that we're spending at different margins. I'm spending in a wasteful way, she's spending in a thrifty way.

That's the situation that advocates of universal health coverage see the U.S. in, when compared to some European nations.

BTW, I think all five of your ideas are good ones. But I still think universal health coverage is a good idea, if done right. And rather than take the pessimistic public-choice theory perspective that "it can't be done right," I'm optimistic that we can look at what other countries have done right and wrong, and figure out something that will work for us.

Good post. Disagree with the following:

"[evidence about how Western European countries spend less on health and are healthier than U.S. citizens]...also implies that the marginal product of more health care, adjusting for income and a few other variables, is zero."

Not really. Do you suppose we're allocating our health care dollars the same way? $1M on cheap, simple preventive care may go farther on average than $1M on bleeding-edge cancer treatments. The anti-US health care crowd seems to argue that we're spending our health care money in a non-optimal way.

There are many downsides to the American practice of linking health care to jobs. One of them is that your medical insurer has little incentive to make sure you're healthy in five years. For example, there've been many claims (which I do not know enough to evaluate) that veteran's health care in the US provides far more for far less.

"it might also be useful to point out that CUBA HAS A SYSTEM WITH RESULTS COMPARABLE TO OURS. Which isn't really all that helpful to my argument. Until you realize THEY SPEND LESS THAN ONE FIFTH OF THE COST, AND LESS THAN HALF THE COST IN GOVERNMENT EXPENDITURES ALONE."

What's actually useful to point out is that CUBA CLAIMS TO HAVE A SYSTEM WITH RESULTS COMPARABLE TO OURS. Cuba, like all Communist dictatorships before them, has long been in the habit of claiming all sorts of things without much regard for such borgeois Western concepts as "truth", "fact", or "accuracy". The Soviets, as I recall, had similar impressive claims regarding the health and well-being of their people, the state of their armed forces, and so on that turned out not to stand up to any sort of scrutiny.

"There are many downsides to the American practice of linking health care to jobs. "

I agree. We need to stop doing that. We don't need national health care in order to stop doing that. The alternative to people having their bosses buy their health insurance isn't limited to people having the government buy their health insurance. They could buy it themselves. Granted, having people buy things for themselves has only been tried in hundreds of other industries for a handful of centuries, but I think it'll work.

Just piling on, 'cause Tyler really deserves it:

First, Tyler, you aren't a Democrat; you are a Republican.

"First, I would not cite evidence about how Western European countries spend less on health and are healthier than U.S. citizens. This data set, if you take it seriously, also implies that the marginal product of more health care, adjusting for income and a few other variables, is zero. "

Sceond, this is, at best, like looking at a raw corelation between two variables, and ignoring significant confounders. Especially as (guessing here) the ENMP (extremely naive marginal product) is probably negative.
When you see a raw relationship between two variables which is the opposite of what theory and history would predict, it's time to be suspicious of that raw relationship number.

As said above, in a certain sick, twisted and useless sense, that's true. That sense can be summed up as Barry's theorem: "for almost any input-output relationship, it is possible to find a situation where the same input magnitude would yield fall lower output values", or, more simply, "no matter who bad things are, it's possible to scr*w them up worse".

It's impressive how many people are willing to dismiss Tyler's comments without even reading the evidence he supplies.

Regarding the marginal value of health care:

(1) A recent comparison of 21 developed countries also found national life expectancy did not vary significantly with medical care spending, after controlling for income, education, unemployment, animal fat intake, smoking, and consumption of pharmaceuticals...

(2) The most respected relevant study is the RAND Health Insurance Experiment, which for three to five years in the mid 1970s randomly assigned two thousand non-elderly US families to either free health care or a plan with a substantial copayment. Those with free care consumed on average about 25-30% more health care, as measured by spending, obtained more eyeglasses, and had more teeth filled. They had more appropriate medical visits, and as a result suffered one more restricted activity day per year. Beyond this, there was no significant difference in mortality, a general health index, physical functioning, physiologic measures, health practices, satisfaction, or the appropriateness of therapy.

(3) An optimistic accounting of the benefits of specific treatments attributes only five years of the forty or more years of added lifespan over the last two centuries to medicine [17].

(4) The small health effects of medicine also raises the question of why exactly lifespans have increased so dramatically. Over the last century, age-specific mortality rates have fallen at a steady exponential rate across developed countries, without noticeable changes due to major medical and public health innovations [98, 61]. Improvements in sanitation are often given great credit, but no effect on mortality has been found among individual variations in water source and sanitation, even among high mortality populations [33]. Average nutrition has greatly increased, but the fact that people who had very high nutrition a century ago had much higher mortality that we see today makes it hard to attribute most lifespan gains to nutrition.

This and more are all in the link Tyler supplied. Now, you can dispute this evidence by marshalling your own to contradict it, or you can give up on the idea that Europeans are healthier because they have national health care systems and so for some reason spend their money more effectively.

No comment on the specific issue here, just a tip that I and others have mentioned before. You have to do the math for your own situation, but you can get up to 50% discounts from doctors if you pay cash. The doctors get the benefit of not dealing with the claims and bureaucracy while you get the benefit of knowing a truer market price, getting the discount and not paying health care premiums. I do recommend catestrophic insurance.

"'I would admit that we cannot take care of everyone and that we face tough trade-offs.'

Why can't we? Other industrialized countries do it. We'd have to raise taxes by a nontrivial amount, to be sure, but we certainly could do it if we wanted to. You don't get points for intellectual honesty by ruling some policy options out of bounds a priori without explaining why."

Ok, lets start with medical innovation. The US subsidizes the whole world in pharmaceutical innovation. Other industrial countries don't have to have free market systems in drugs because ours pays for ours and theirs.

"Ok, lets start with medical innovation. The US subsidizes the whole world in pharmaceutical innovation. Other industrial countries don't have to have free market systems in drugs because ours pays for ours and theirs."

Which is in fact an explanation. But it isn't necessarily TC's explanation, which is what people are asking for. It also suggests that TC should have written "or" rather than "and".

Tyler wrote, "I would admit that we cannot take care of everyone and that we face tough trade-offs."

I agree. I take Tyler's statement to mean the following: If the U.S. were to guarantee that every resident will be given all the healthcare that he/she could arguably need, no matter the cost and no matter the person's ability to pay, and were to actually try to make good on that guarantee, the compulsory wealth transfers that would be needed would be so great that U.S. productivity would stall and its standard of living would drop accordingly, with the result that we could never reach a point where everyone would get the level of care that some people get now.

I find it very, very depressing to read these generally mean spirited attacks, most of which don't bother making an honest intellectual attempt to understand Mr. Cowen's point of view, let alone provide evidence of why he his wrong and/or right. I applaud those few that have used this forum as a means to exchange ideas and learn from one another, rather than scream angrily (not to mention pointlessly).

Well, geez. I asked Tyler for an explanation of why he doesn't like the european systems -- they're not a "good idea." And he gives it now. I'll have to sit down and read what's said in the links he has provided before I can respond directly to him. But I must say, if the commenters here are from Drum, they're not so impressive. I don't care who Tyler votes for; I only care whether he's persuasive. And he's given me a lot to think about, and I will. I suggest that attacks against him or his perceived personality are beyond useless.

Javier, I could have used a link or two for your assertions, unless they're in the links that Tyler provided.

Oh, and the dealie about immigration: This is a serious problem, not trivial at all. Tyler tends to shrug it off by saying that we don't owe them medical care. But at a pragmatic level, we do. If we allow them in, we owe them medical care so that they don't cause medical problems here. Unless we deny them emergency care when they have emergencies -- that is, deny them completely -- we should invest in their preventative care in hopes of reaping cost savings down the road, both for them and for the people they interact with. Bugs don't respect boundaries. Yet -- I agree that this opens up huge cost requirements. Hard darned problem.

Step up R&D subsidies through the NIH and our university system, both high quality institutions. Their autonomy and micro-fiefdoms provide a good framework for risk-taking and innovation.

Sorry, but this won't work. The problem isn't that we're not spending enough on the NIH. It's that doctors have no incentive to incorporate a majority of the NIH's work. For example, the NIH has shown simple regular maintanence will control diabetes. But doctors don't have enough profit incentive to administer this kind of ongoing care. Until we find a lower cost alternative for medical delivery, you might as well bury the money in a hole.

Ralph, as I said in my post, everything I quoted from was from the links that Tyler provided.

SteveSC, bad use of straw men arguments, 20 points from Griffindor.

And just to let everyone know just in case they don't - the Canucks are pouring 41 billion loonies in over 10 years to improve their system - what military?

Brit was 5.6 billion euros or $, can't remember, the froggies 15 billion euros/or $ so their system wasn't as lousy as Britain. Scotland 2 billion, the Ozzies and Kiwis were also spending lots o cash to improve theirs, too. The gov't isn't the panacea some would think.

The middle-class Canucks are taking out HELOCs to get their elective surgery here.
Private healthcare business booming

Tom Blackwell
National Post Saturday, April 23, 2005

Patients fed up with long waiting lists in Canada are fueling a fast-growing demand for brokerages that arrange speedy service in the United States as well as in Quebec's burgeoning for-profit medical industry.

Brokers and other similar companies say business has as much as tripled over the past year as Canadians apparently become more comfortable with paying for diagnostic tests, second opinions and even surgery.

They say their patients include not only the wealthy but also middle-class people willing to take out second mortgages or lines of credit to pay for faster care.

Driving the move are Canada's lengthy waiting lists for many medical procedures. A study last year found Canadians waited an average of 8.4 weeks from their general practitioner's referral to an appointment with a specialist in 12 different medical specialties, then waited another 9.5 weeks for their treatment. Those wait times are almost double what a similar study found in 1993....
----------------
And there's your wonderful single-payer system. Illegal for-profit system, but Quebec is always the cultural exception.

Re: "just how _does_ spending billions of dollars for administrative and marketing overhead pay for innovation, anyways? "

The mere posing of that question exposes such a profound ignorance of market economics, it makes one shudder.

Think for a moment. How is it that you are able to buy a computer at Wal Mart that is cheaper now than it was 5 years ago, despite all their admin and advertising overhead (from *both* the store and the computer company)?

And think, are Medicare's administration costs really cheaper than the private sector's, since they get to "ignore" costs normally associated with administration, such as fee collection and paperwork (both tasks delegated to other agencies or the private sector, and seemingly "free")?

And think about it, why is it that the state-owned industries in Britain, what with their "cheap" admin and no marketing for decades after World War 2, failed to such a fantastic degree that in the mid 1970s it has to take a 2.3B pound loan from the IMF, like some 3rd world country? The industries were eventually sold off under Thatcher, and only then began to recover. Ask yourself, why is that the case?

Re: "copycat drugs that do the same as generics but have fresher patents?".

Ignorance again.
Celexa and Zoloft are "copycats" of the antidepressant Prozac. However, they both have different side effect profiles, and are effective in some patients that Prozac failed to help. Similarly, Zoloft differs from Celexa in its side effects and efficacy.

Or to put more simply, Zoloft, Celexa, and Prozac are "copycats" in the same way that Apple, Dell, and HP are computer "copycats."

Wouldn't we all be better off if we just let *Andrew* (ArC) choose our one single antidepressant drug for us? He seems to know the topic well enough.

EEK - Sorry, guys, longer than I thought.

This is what I like to hear/read, "real solutions" that do not call for more taxes and pass more ridiculus laws.

Keep up this type of good work!

"That sentence meant nothing at all. "

OK. Let's try one more time. The improving price-performance ratio of computers is unique to microelectronics, due in large part to 'process shrinks', which means manufacturers have a well-known way to get more performance: make transistors smaller. I know it's not entirely straightforward; CPU designers have to deal with latency and slow memory and all sorts of other details. But the engine of growth is relatively well understood; more so than pharmaceuticals. Do you really think drugs have anything equivalent to Moore's Law?

(Yes, I know it's not a real 'law' of anything.)

"Just ten years ago, all that was available OTC was benadryl."

Goalposts moved, man. You said 5 years ago in your extremely bogus computer analogy, and I know the OTC allergy medication I took *5* years ago is the same one I take now.

Why are you being so hostile, anyways?

The problem is that even in areas that have potential 'process shrinks' the FDA stands in the way. What would have happened to progress in microelectronics if we had a government agency that not only spent a couple of years evaluating the safety and quality of every new component in a computer (before it was allowed on the market), but also required every computer assembler to stress test every combination of parts for a year to make sure they were compatible? Even if another assembler had successfully tested the exact same combination? Moore's Law would suddenly become a 10% improvement every 10 years.

Real life example: Injectable medication, only constituents are the active pharmaceutical ingredient (API) and salt water. Generic manufacture tries to make less expensive copy. In the manufacturing process, the manufacturer adjusts the pH to make the end product identical to the branded product, using a grand total of 1 drop of HCl for every 7 gallons of product. End product is chemically indistiguishable from the branded product by every known analytic method. FDA rules that this is a new drug that must go through the more expensive and longer duration new drug approval process.

Now that I think about it, I think I overestimated progress at 10% every 10 years...

Kevin, you're right that mass production is hardly new. But the /scale/ of computer improvement is so unusual that I find it hard to be swayed by analogies from anything else to computers. Sure, let's go with ten years ago instead of five. Ten years ago, Windows 95 was struggling to run on anything except a top-end 486, and 8 mb of memory was recommended (but definitely not standard!), if my faulty memory serves. The anti-allergy medicine Reactine was just then making the change from prescription to OTC. And now, we have WinXP on Pentium 4s and AMD 64s with /half a gig/ of RAM on the one hand... and OTC Reactine on the other.

Also, I honestly can't figure out what you're saying in the third paragraph there. Are government restrictions holding back medicine (due to their more onerous regulation), or is medicine on pace with computing? Or do you mean that despite the greater amount of regulation, medicine is already holding pace with computing, and so less regulation would mean even faster innovation?

ArC,
What I am trying to point out is that you've obfuscated something that is really quite simple. In a free market, items are bought and sold. The prices are set by willing buyers and sellers. If prices are set by any other method, the market becomes distorted, and the usual rules do not apply. Failure is inevitable, though.

Computer technology differs from medicine primarily in that medicine operates in a market that is largely controlled by the government and 3rd party payers. So unlike the freer market characterizing chips and memory, prices do not reflect the choice of the ultimate consumer.

Computers are less unique than you think. You've become lost in the details. The bigger picture is that computers have become cheaper over time for the same reason that most technologies become cheaper over time. It's how a free market works.

And medical care doesn't work precisely because it is not in a market at all, but a very distorted system that tries very hard to resemble a market, but fails repeatedly, on several levels. In short, you're barking up the wrong tree.

1.1% ArC. Not overseas - just out of the country.

http://www.fraserinstitute.ca/admin/books/chapterfiles/WYT2005pt1.pdf#

Sorry.
"The greatest failures have occurred in those ECONOMIES wholly controlled by the governemnts,"

Re:"...easily accessible forms of low-cost high-quality "simple" care, such as maternity clinics, family doctors, long-term care"

Appearances notwithstanding, I see little evidence this is true. Infant mortality rates in the US are higher than in other nations for numerous reasons that would not improve depite greater access to care (if access were indeed a problem to begin with, which has not been demonstrated).

Infant mortality rates are higher for mothers are adolescents, did not complete high school, are unmarried, or who smoke during pregnancy. Infant mortality is also higher for moms who had no prenatal care, but it is unclear why, given the massive efforts of Medicaid, this access is not used.

Other causes cited: more premature births, more babies with low birth weights, more multiple births, and earlier Caesarian and induced deliveries. The increased use of in-vitro fertilization and other reproductive therapies that result in multiple births are linked to an increased risk in low birth weight among single births. In other nations, such preemies do not get any high tech care, and perish, uncounted in the infant mortality stats (counted instead as miscarriages). Other nations do not spend money on fertility drugs which result in more multiple births. And more US C-sections and induced deliveries are a direct result of lawsuits (CYA).

"Out of approximately 4 million births, 27,977 infants died in 2002, up from 27,568 deaths in 2001. The rate of infant mortality — considered a key indicator of the nation's health — had steadily declined since 1958. Since 1933, infant mortality has declined nearly 88 percent — from 58 deaths per 1,000. A slight upward blip was seen in 1957-58 but rates dropped again." (http://www.ajc.com/news/content/news/0204/12infantmortality.html)

Although the report stated "Black infants are more than twice as likely as white infants to die in the first year of life — a trend continued in 2002. Lack of access to health care and lifestyle factors, such as domestic and economic stress, may contribute to the disparity", it did not demonstrate any lack of access at all. I am unsure poor asccess exists except for lower middle class workers not on Medicaid.

Kevin, I am talking about facilities that do not exist in the US at all, so differential access is not the only concern (although wealthy americans have better replacements). Family doctors that live and work from a regular house nearby patients are a much better and cheaper option for primary care than emergency rooms, which have become the first stop for the non-insured. A community health center that sends parents notification that a baby needs immunization, arranges post-natal care, etcetera. A lot of these simple forms of care are not easily available in the US.

"Of course it doesn't ArC, and that was not my argument. Red herring."

What? You wrote: "If prices are set by any other method, the market becomes distorted, and the usual rules do not apply. Failure is inevitable, though." I took that to mean that markets distorted by regulation were bound to fail.

"it did not demonstrate any lack of access at all. "

If memory serves, the disparity between adult blacks and whites disappears when we consider only those served by VA hospitals*. Or in other words, the evidence in that study suggests black Americans not in the VA system seem to have worse access to medical care.

* http://jama.ama-assn.org/cgi/content/abstract/285/3/297

Kevin, it has a lot to do with incentives and education systems. In most European countries, students can go to medical school at 18, largely financed by the government. The family doctor track is the shortest (usually 6 years + some trainee period afterwards). These people do not become specialists but function very well as gatekeepers and in dealing with small medical problems. For instance, it is pretty crazy that I have to go see my superbly trained primary care physician at the GW hospital when I need a new allergy medicine prescription or have a backache.

It is unfortunate to hear so many lack health insurance. We really need to improve our health care system. Health insurance is a major aspect to many and we should help everyone get covered.

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