Discussing health care seriously

In my discussions with people on serious and controversial topics, I have some simple rules of thumb to tell me tell whether the discussion is worth pursuing or whether the other person is not serious and talking further is a waste of time.

For example, when discussing evolution, as soon as someone says something along the lines of Mel Gibson’s “If we descended from monkeys, then how come there are still monkeys? How come apes aren’t people yet?” then you know that you are dealing with someone who is either being willfully dishonest or is so ignorant of the basic facts of the topic under discussion that it is not worth continuing unless one is willing to spend a lot of time to bring that person up to speed. The wrongful use of the second law of thermodynamics is another example of a warning sign.

A similar situation applies to global warming when, during a cold or snowy spell someone triumphantly suggests that this has conclusively proven that global warming is a myth.

In discussing politics, the signal is when one makes a criticism of some action of the US government (such as its decision to ignore habeas corpus, or to invade Iraq, or its numerous covert destabilization actions in other countries) and the other person replies “If you don’t like it, then why don’t you go to Russia/France/China/Cuba/Sweden/(fill in the blank for whatever other country the speaker does not like)?”

In all these cases, the signs are clear that there has been no attempt by the other person to really engage with the issue and he or she has resorted to what he or she thinks is a clever debating point but in actuality has little or no content behind it.

In the case of the debates over the merits of a universal, government run, single-payer health care system, the signal that someone is not serious is when he or she trots out the waiting times for hip replacements in Canada as an argument about how the Canadian system is so terrible in comparison to the US. In the wake of the release of Michael Moore’s film Sicko, we can expect to see this being trotted out repeatedly, as indeed it already has.

As Kevin Drum pointed out a few months ago, the hip replacement argument is a sign of egregious cherry picking of data.

When comparing huge and complex systems like the health care or education systems in different nations, making point-to-point comparisons of isolated cases is of little use. No system is going to be better at every single thing, so this kind of debate results in each side selecting just those pieces of data to suit its purposes. There are probably some elective procedures for which there are longer waiting times in other countries than for those with high quality insurance plans in the US. It would not surprise me in the least if access to tests using expensive equipment like MRI machines is easier in the US (for those who have the requisite insurance coverage, of course) than it is for people in other countries. Health care in the US is aimed at servicing the well-to-do, because it is they who are the decision and policy-makers and as long as they are kept content, they are unlikely to want to make changes that reduce the profits of the health care industry, let alone eliminate them entirely, even if the changes benefit the general public.

One needs to look at aggregate measures to better compare quality and cost across nations. For example, the World Health Organization in 2000 put out The world health report 2000 – Health systems: improving performance in which it used the following measures for the comparison for health systems, using measures of both goodness and fairness:

  1. overall good health (e.g., low infant mortality rates and high disability-adjusted life expectancy);
  2. a fair distribution of good health (e.g., low infant mortality and long life expectancy evenly distributed across population groups);
  3. a high level of overall responsiveness;
  4. a fair distribution of responsiveness across population groups; and
  5. a fair distribution of financing health care (whether the burden of health risks is fairly distributed based on ability to pay, so that everyone is equally protected from the financial risks of illness)

Based on these criteria, according to the WHO study (p. 152), the US comes in at #37 in rank internationally, compared to France (#1), England (#18), Canada (#30), and Cuba (#39).

Michael Moore’s Sicko (which you should really see) points out that on measures like life expectancy at birth and infant mortality rates (i.e., the number of infants who die before reaching the age of one year for each 1,000 births), the US lags behind its developed world counterparts, even though its spends far more on health care as a fraction of its GDP (13.6% in 1998) than its nearest competitor Germany (10.6%). Per capita spending is also highest is the US ($4,178) with the next highest being Switzerland ($2,794).

The reason the US gets so much less for the money it spends on health care is because of the vast amounts siphoned off to the insurance and drug companies, partly due to profits and partly due to a huge bureaucracy to handle the complex billing and processing process involved with private health insurance. Such costs account for between 19.3 and 24.1% of health care spending in the US compared with between 8.4 and 11.1% in (say) Canada.

 image001.pngThere is a strong (negative) correlation between infant mortality and life expectancy, as can be seen from this graph, where each dot represents the data for a country, along with a linear regression line. The implication is clear that the best way to improve life expectancy is to reduce infant mortality. The reason that many developing countries have high infant mortality rates and resulting low life expectancy is that lack of access to clean water results in diarrhea and this leads to dehydration, which is often fatal for infants. (As an aside, the international conglomerate Nestle deserves widespread condemnation for its policy of marketing infant formula in the developing countries, despite the lack of easy access to clean water to prevent infection. Breastfeeding is always preferred except in exceptional cases, but because of the Nestle marketing campaign became perceived as inferior to formula.)

But when comparing the US to the rest of the developed world, access to clean water is not the main issue, so widespread access to health care emerges as the prime suspect for its low ranking. For example, infant mortality rates for non-whites in US cities are two to three times as high as the national average.

What really irks many people in the US about Moore’s film is perhaps not so much the adverse comparison with Canada, England and France. People who for some reason are enamored of the system here will complacently trot out once again hip replacement waiting times to claim a spurious superiority. It is the fact that among the 221 countries listed, Cuba’s infant mortality rate (6.04, rank 40) and life expectancy rates (77, rank 56) are almost identical with the US infant mortality (6.37, rank 42) and life expectancy (78, rank 45) that really rankles.

The US government’s implacable animosity to Cuba, trying to strangle its economy with boycotts and embargos and repeated attempts at destabilization and even assassination of its leaders, has to be one of the cruelest policies ever implemented towards a country that is not a threat to its security. And yet despite that deliberate attempt at destroying the Cuban economy, Cuba has managed to create a public health system that is a model for third world countries, and produces results in key indices that are comparable with the US. Cuba is legendary among third world countries in its generosity, sharing its medical personnel and expertise around the world.

Kevin Drum wonders if Moore’s use of Cuba in his film was a clever public relations strategy, knowing that it would trigger the almost reflexive anti-Cuba venom that exists in certain quarters in the US and that they would make a huge fuss, thus giving him free publicity. “Moore’s brilliance at getting his mortal enemies to do all his publicity for him is unparalleled.”

Drum may be right. In the weird media world we live in, it is not enough for Moore to accurately portray the scandal that is the US health system compared to its peer countries. That information has been out there for a long time, and ignored by the power elites. He had to create a fuss and by going to Cuba, he did so.

POST SCRIPT: This Modern World

Cartoonist Tom Tomorrow sums up the predictable responses to Sicko by the apologists for the US health care industry.


  1. Erin says

    Out of curiosity, are the life expectancy data adjusted to dispose of the effects of actually dying in infancy for the purpose of that regression equation? Because of the way outliers influence means, it seems to me that if you don’t exclude those people from your life expectancy calculation, part of your correlation will be due to something relatively uninteresting. That’s not to say there wouldn’t be a relationship left afterward (it’d be a little surprising if there weren’t).

    Also, I think another reason that a lot of people hate Moore is that he’s an obnoxious demagogue who lowers the level of political discourse. I don’t have a strong opinion on his politics (I’m the civil libertarian type of liberal and don’t have strong economic intuitions), but Roger and Me seemed to be the story of a man with a grudge whose only plan of action was to annoy people to death, so I’ve not bothered to see the rest of his movies. He’s less vile than Ann Coulter, but that’s a pretty low standard.

  2. dave says

    Infant mortality rates are a bad measure to use because the definition of ‘live birth’ changes from country to country.

    “The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don’t reliably register babies who die within the first 24 hours of birth.”


    Also, the real burden on costs is not the amount siphoned off by drug and insurance companies (but they are a problem) but rather the money spent on end of life care.

    “Estimates show that about 27% of Medicare’s annual $327 billion budget goes to care for patients in their final year of life.”


    The problem is we live in a health culture where there is always one more test, one more treatment, one more something that can extend life for a few more days or weeks.

    No one wants to accept that a family member may die, so every possible (regardless of expense) treatment is applied. Subtract this type of spending and the numbers look much better.

  3. says

    Erin makes a good point about Moore. I haven’t seen Sicko, but his other work strikes me as having the same level of discussion potential as Mel Gibson’s statement about evolution. Still, that’s not really relevant to the point I like to make.

    I remain fairly uncertain where I stand on the free market vs. nationalized health care debate. In part, it’s because I’m not as well read on the subject as I should be to take a truly informed position. I tend to see it as a debate over which large, impersonal bureaucracy gets to manage me and my health. I’m primarily a fan of individual and personal choice in as many things possible — including my own health care — but as long as there’s a pooling of money process that takes place, there has to be some form of rationing behind the distribution of that money, and that seems to require some organizational structure to manage that distribution. As both the pool of money and the supporting structure to manage it grow, it becomes less and less personal.

    As a fairly ardent libertarian, I tend to dsitrust government activity and favor market activity. I was about to say I also avoid the pooling of money, but then I remembered my mutual funds… hmm…

    Still, I have many moderating traits. For as much as I can find many faulty and failed government programs, I can find many successful ones, and I can find many faulty and failed market-driven initiatives. Certainly, there is no silver bullet.

    Lastly, I tend to find words like “universal” a little off-putting. It strikes me as overly utopian, and thus a little out of touch. I don’t accept that universal equates to fair, as has often been presented to me in this debate.

    I think in the end, I come to this conclusion: any policy structure that manages anything related to 300 million people (or even one million, etc.) is going to have losers and winners. Debates over the nature of these policy structures tend to focus on picking the winners and losers. Because of this, I don’t really have faith or leanings to either the free-market side or the nationalized management side of the health care debate. Both sides are just trying to pick the winners.

    Hmm… I suppose if I’ve rambled on this long, I should probably post something over on my own blog. We’ll see if I get around to it. 🙂

  4. Rian says

    The question I’d have is this: Is it possible for the institution of such a single-payer system to cost no more than it does now under the current system?

    I’m simply not willing to pay to institute such a system, even if it does bring better health care. If you can implement it with a net zero increase even over the short-term, then I would certainly be in favor of it (more efficient health-care for no extra outlay would be nice).

    On a side note -- how much of our extra outlay is due to Americans increasingly looking like this:


  5. says

    I am not sure why there is this impression that universal health care is this incredibly complicated, untried, untested, more expensive thing. The fact is that is has been implemented many times by almost every developed country and the cost-benefit analyses are out there for all to see. In every case, it is cheaper than what it costs in the US.
    All we have to do is adapt an existing model for our particular situation.

    There is far less bureaucracy for the individual in such systems because you as an individual do not have to negotiate with insurance companies each time you access services.

    There is a group working to get such a system in Ohio, called the Single Payer Action Network Ohio.

  6. Erin says

    Mano, I suspect that one other thing that makes our society different from the others that have implemented single-payer or other nationalized healthcare systems is our litigiousness. So I’m not going to be satisfied with any “but it’s cheaper over there!” comparison that doesn’t address the lawsuit issue. Do you know of any reports that deal with this specifically?

    (Even though I know our litigiousness makes healthcare costs monstrous for us all, I would hate to see our ability to sue for bad care removed — especially if the government takes over. Lord almighty, I can only imagine what would happen if we put the Christianists in control of healthcare…! Goodbye, contraceptive coverage; goodbye, STD vaccines; hello, more of the same, but this time from my actual GP.)

  7. Rian says

    What I’m saying, is that I’m not willing to pay the price to convert the existing system over. There will be such a price, especially if there is any reduction in the business of the private healthcare providers -- they will fight any such plan in the courts and have an enormous amount of money to back a campaign to protect their own profits.

    I’m satisfied with the current level of healthcare in this country, and as such do not wish to change the current status quo on the subject.

  8. says

    As far as I know, the main reason countries with nationalised health-care systems spend a lot less per person is that they use the bargaining power of a nationwide drug purchasing network to control the cost of prescription medications. Certainly the same dose of the same medicine costs astronomically more as a private purchase in the US than what the UK NHS was paying on my behalf back when I lived there (fortunately I’ve always been able to maintain health insurance cover over here, otherwise I would never have been able to afford the stuff -- as it is I just read the “insurer paid” column on invoices out of curiosity).

    A lot of the arguments against single-payer health care systems seem to presume that they would at a stroke remove private health care. This need not be true -- in Britain, for instance, there is both an NHS and a private health insurance system. It’s an important point because it means that no matter how bad the nationalised health-care system is, those who could afford private insurance anyway will still be able to opt out of it, but those who can’t will still be served better than they are under the present US system. Yes, it sucks that an NHS patient can wait over a year for an important operation, but this is still clearly better than never being able to have it.

  9. says


    The life expectancy figures quoted in the graph are for at birth. That is how they are usually quoted although one can find tables for people at different ages, usually for insurance purposes.

    It is possible to do a rough calculation to see what would happen if you factor out the infant mortality. For example, for a country that has life expectancy at birth of 50 years and an infant mortality rate of 100, without the infant deaths, the life expectancy rises to about 55. So there are still a lot of other factors at play in raising life expectancy, of which the quality of health care is one.

  10. says

    The important point of opting out was raised, I think in Eldan’s post. How does one opt out of a universal coverage system? Yes, I can purchase private insurance/medical coverage, but I’m not really opting out; I’m simply purchasing additional services as my taxes are still funding universal coverage. What if I want out completely? If for some reason, I want no coverage whatsoever, do I get a tax refund? Or if I do get other insurance/coverage and make no use of the universal system, do I get to truly “opt out” and get those taxes refunded as well?

    Of course, giving tax refunds to those who opt out defeats the revenue scheme for universal coverage. I should have a right to no coverage, though, and should face no financial burden for choosing that route.

    To Mano’s point about adopting an existing model, I don’t see a governmental bureaucracy being any easier to navigate than a corporate bureaucracy. We’ve all had to navigate governmental bureaucracies and it’s not usually a pleasant experience. Government bureaucracies also tend to be easily politicized, as was mentioned in Erin’s post. Witness, of course, the overpoliticization of the FCC in regards to decency in broadcasting. The Christian right could do some pretty devastating things if they get control of the system.

  11. says


    I’ll be addressing the important points you raise later this week (probably Tuesday and Thursday).

  12. says

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  13. says

    Do you find that children, especially the boys are getting more and more feminine? It’s got to do with the water we drink and the food we eat. Where is Earth heading?

  14. Mike says

    One may “select out” examples, like onconscionable delays for certain medical procedures like hip replacements or MRI’s to diagnose brain or other CNS problems, either to illustrate a failing in the single payer system, or, to “suit the purpose” of making an unfair criticism by choosing a rare problem in an otherwise satisfactory system. It depends upon the actual percentages of delayed procedures in the single payer system compared to our “mixed bag” system in the USA, or, to some other more market driven system. Calling this “selecting out” unfair, or, using it as a valid illustration of an unsatisfactory system, requires this statistical confirmation (or disconfirmation). Assertions without supporting data are unconvincing.

  15. Bob says

    Are mothers with problem pregnancies in Cuba encouraged to abort, rather than burden the system?

    Are countries with high immigration percentages likely to have higher mortality rates than countries with high emigration rates?

    Statistics can be somewhat tricky to interpret, especially if reasons behind the data are obscured.

  16. says

    I was able to quit smoking without the use of the drug companies and their pills with the awful side effects. I used the quit smoking laser therapy and quit within 1 hour. After that, my wife and father quit there too. I am so tired of the U.S. medical system and the cost of healthcare. Right now the pill that Phizer has out to help people to quit smoking is killing them. People are commiting suicide, experiencing hallucinations and severe nausea with these pills and they have to take them for months and months. I quit smoking in 1 hour with an all natural treatment. If anyone is interested, the clinic was http://www.healinglaserclinics.com and it only cost me 200.00

    I’ll take a natural treatment over those pills any day of the week.

  17. says

    You make a very good point but I think your analsys of the chart is slight incorrect. Yes, there is a correlation but this does not imply causation.

    By working on bettering infant mortality, we probably do help to increase life expectancy but I am sure that there are many things we can do to increase life expectancy that have a zero effect on infant mortality too.

  18. says

    It is very true that life expectancy is low because infant mortality is high. Infant mortality is not talked of much like how importance is given to aids and cancer as this has been in history for ages. Pregnant mothers need to really be given special attention during the Pregnancy period. As long as the child is inside the mother’s womb, it should be remembered that the mother’s mouth is the child’s mouth and utmost care should be taken. After the child is born, the baby should be treated like a baby with sterile conditions till it gets accustomed to the world.

  19. says

    I was shocked with the infant mortality report. I am sure this topic needs more awareness especially to all the pregnant mothers and the boding between the child and mother can improve some results.

  20. says

    I believe that life expectancy and infant mortality rate vary depending on where in the part of the world you are located. And is greatly affected by the culture and way of living of the people. Smoking for instance is one major factor affecting life expectancy and infant mortality. Most of us are aware of the effects and complications of smoking resulting to shortened life expectancy, and also giving low mortality rate for babies from smoking mothers.

    It’s good to hear from here that expectant mothers considered quitting smoking for the sake of their baby. This is the first way of showing your unborn child of how much you love them.

  21. says

    This is a really fascinating article -- I am so glad that I found it.

    I have not seen Michael Moore’s movie, Sicko, but I will most certainly be getting it out asap.

    The healthcare system is such an issue in the US -- hopefully the mess can be fixed and there can be a way that adequate healthcare can be available for everyone, not just those who can afford it.

  22. says

    I never knew there was such a strong negative correlation between infant mortality and life expectancy. That’s sad. Pregnancy Miracle is something women should look at.

    @Sally -- I saw Michael Moore’s movie and I have to say it was very controversial. It’s worth a watch.

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