World’s greatest healthcare (TM)

What does it mean when a US politician like Chris Christie tells the Republican National Convention the US has “the world’s greatest healthcare system”? Is it like when kids buy a “World’s Greatest Dad” mug for Father’s Day: An expression of affection for an ill-favoured thing, but mine own?

One of my formative political experiences was the summer during graduate school, when I listened on the radio to broadcasts of the US Senate debating the Clinton healthcare proposals. What struck me above all was how the senators universally (it seemed) invoked the unmatched excellence of American health care. “The envy of the world”, “best health care in the world”. The only difference of opinion was, of course, that opponents of the reform said that tinkering with this paragon of perfection would inevitably be disastrous, while supporters argued for making this blessing available to more people.*

So, the politicians certainly appear to believe it, and to believe that it should have policy implications; or to believe that a significant portion of the public believes it; or to believe that a significant portion of the public will respond favourably to the assertion, even if they suspect it is untrue. Is it cognitive dissonance? We’re America dammit, and being the sort of people we are, we certainly wouldn’t put up with a ramshackle healthcare system.

I found this particularly striking, as I was just back from two years in Berlin, and I knew for a fact that Germans were not envious of US health care. Perhaps unsurprisingly, US health care was hardly mentioned at all in the press, though when it did come up, at was almost inevitably as a negative example. For instance, there was this interview with Health Minister Horst Seehofer (from the most right-wing mainstream party, the CSU), where he was asked whether his proposed reform of dental insurance would lead to Germany becoming “like the USA, where you can read a person’s income class from the condition of his teeth.” I knew that the US trailed most developed countries in most important measures of quality of health care: Infant mortality, remaining life expectancy at age 60,  It still does. The US does well in high-tech cancer care — as some boosters like to emphasise — but even there there is no clear international leader — different cancers, and different choices of statistics, put different countries ahead — and the huge lead that the US has in prostate cancer survival in particular is a pretty dubious benefit, since it is the result of overdiagnosis. (Clearly one way to increase 5-year survival rates is to find more minor cases of the disease.)

I haven’t found any polls where Americans were explicitly asked whether they think the US has the best healthcare in the world. According to a recent Gallup poll, most are personally dissatisfied, and 19% of Americans say that someone in their family has postponed treatment for a serious medical condition in the last twelve months because of cost. (Another 13% have postponed treatment for a non-serious condition.) (It’s hard to know how to interpret this; it depends a lot on how large the respondents think a “family” is.)

If it is true that many Americans think their healthcare is clearly the best in the world, I suspect it’s on the same reflexive level as when an American visiting Germany for the first time asked a German friend of mine whether they have refrigerators in Germany: Real life happens in America, the rest of the world are vague huddled masses talking difficult languages and aspiring to emigrate to the US.

I doubt that many of those who praise American health care have any clear impression of what alternatives actually exist. Most people probably can’t imagine what a really different system would be like. As regards Canadian Medicare there’s an obvious observation bias, since Canadian healthcare impinges on the US only when patients are sent across the border because of service bottlenecks at home, or choose to pay for quick treatment in the US rather than wait. Britain is culturally the next closest country, and if Americans think about the British National Health Service at all, I suppose they imagine it as being pretty much like what they know in the US, but you also have to wait 6 months to get a hip replacement.

It’s hard to imagine, if you are not familiar with it, how much constant low-level stress and worry about medical bills is taken for granted in the US, that simply drops away in the UK: feeling cheated by opaque billing practices, worrying about the danger of losing medical coverage when changing jobs, wondering whether the cough is bad enough to risk a random medical bill for. And then when you have serious health problems, or an emergency, just at the moment when you can least deal with the stress or make significant financial decisions, you’re bombarded with costs and decisions. Do I go in the ambulance? (is this ambulance in my insurance company’s “network”? and if it is, what about the hospital that they take me to?) What if my child is born with a serious medical condition? (Some insurance companies claim that “advanced maternal age” is a pre-existing condition for any expensive pregnancy outcomes, and try to withhold payment on that basis. Fortunately the pre-existing condition scam is being eliminated by the Affordable Care Act.) Is the doctor or paramedic recommending this course of treatment because it’s good for me, or because he needs to bill someone to cover the cost of the equipment? All of that falls away in Britain. It’s by no means a perfect system, but it goes a long way to getting the incentives right. And when you’re in urgent need of medical care, you don’t have to wonder about price comparisons, and they’ll ask you only about your medical history, not your credit history.

The US system — if it even deserves to be called a system — seems to me horrid. You feel constantly like you’re being abused and taken advantage of. When someone has a fainting spell in a public place, the paramedics pressure him to go to the hospital, when he might just need a glass of water. They’ve made the trip, and they won’t be paid unless they can bring a body with them. And there’s no way to know if the bill will be $100 or $1000. I remember the Port Authority Bus Terminal in New York used to be overrun with these sorts of people, offering to “help” carry your bags or show you how to get to your boarding gate, and then charging you if you’d even stopped long enough to listen to them. Honest tradesmen tell you their prices before you accept their services. Taxis are required to post their fares conspicuously, even though they can’t run the fare much beyond $100 under normal circumstances.

Why do the paramedics not need to explain to people “The charge for bringing you to the hospital will be $1000” before they get into the ambulance? And if you think that sounds ridiculous, that you can’t expect them to be discussing money with people who are ill or injured, then you must think the whole idea of leaving health care to the private market is ridiculous.

We have insurance that purports to cover children’s vaccines 100%, but when you go to the practice to get the vaccine the nurse talks to you for a few minutes — just taking the medical history that’s already on the paper forms — without announcing that this is a “consultation” that they are going to bill you $100 for, and that unlike the vaccine, the consultation is not covered at all by the insurance. And then you have copays that are supposed to be 25%, except that somehow the insurance company seems to negotiate a discount on its portion, so somehow your 25% of the nominal cost is more than 50% of the real cost.

On top of that, my impression of general practitioners in the US, compared to those in the UK and Canada, is that they’re by and large not very bright. The UK has made quite a lot of progress toward equalising pay between GPs and specialists, so that general practice wouldn’t be the collecting basin for the med school washouts. (I once needed to see a GP in France, where I didn’t have relevant insurance, and the fee for the office visit was openly posted. As I recall, this doctor also made a house call, and charged about 300Fr — about $50 at that time.) And it seems that you always have to wait for days to see someone at a medical practice in Berkeley — and once you’re there you sit for hours in the waiting room — whereas in Oxford there never seemed to be a problem fitting someone in when they were ill.

It’s true that in the US, if you are among the elect with top-quality health insurance — or the elderly, with their own socialised health system — you may get your cancer biopsy or your CAT scan immediately, rather than having to wait a  week or two, and that certainly saves some time of worrying. And you’ll have a better-appointed hospital room in the US, possibly a private room. On the other hand, the US spends 2 1/2 times as much as the UK per person on health care, despite leaving one sixth of the population with no health insurance, and yet for most people at most times the UK health care experience is not just almost as good, it is substantially better. And that is all the more true for France, which is really considered by experts to have the best health care in the world, and spends only half as much as the US per person.

Interestingly, I think the parochialism bias works in the opposite direction in the UK. I wrote a few years ago about how much I admire the NHS, but how the nature of a national healthcare system is to focus attention on the system’s failings, so that much of the British public, not viscerally aware of how bad things could be, constantly feel like the system is failing. That’s not a coincidence. As free market enthusiasts should realise, it’s precisely the fact that flaws are ruthlessly exposed to the light that makes the NHS so good (though, of course, it would be even better if the British were willing to spend as much as the Western European average, investing their tremendous efficiency in better care rather than in tax cuts.) In the private sector, waste and corruption can continue pretty much forever, as long as you can keep finding a “greater fool” to buy your product, whereas government services are constantly being poked at by the opposition, by journalists, by academics, and by the general public.

* Maybe my impression of the congressional debate was distorted, or maybe the Senate debate was more monotone than the House debate. I’ve just glanced through the transcripts of the 1994 House debate, available online, and discovered at least one exception, Oregon Democrat Ron Wyden, who argued that US health care could actually be improved, and cited statistics on superior health outcomes elsewhere to support this.