In the furor over the health care legislation there have been comments about 'destroying the world's best health care system' by some pundits, while others say America as fallen behind in health care as shown by longevity statistics in countries with government health care. Is longevity the best measure? Is short waiting time for procedures the best measure? Those 2 measures would give opposite rankings when comparing America and western Europe.
I was discussing this with a colleague at work who related his story. In 1989 he tore a tendon in his leg and had surgeons describe to him the incision that would be made from his knee to his ankle to repair it and the resulting 3 months on crutches. Not liking this, he found out that there was a new surgical group here and the founder used to play on the rugby team he was playing for when injuring his leg. This surgeon provided tendon repairs to the Atlanta Falcons and Braves with a then brand new procedure, an arthroscopic method with a very small incision and ability to walk without crutches in a day or two. He contacted him, and the surgeon was willing to take him on because of the rugby team connection. In 1993, the other leg was injured. This time, all the surgeons in town were using the new procedure. In 1999, he was Denmark on business and met a man on crutches who had been injured playing soccer, and there the surgeons were still using the old procedure. They were only 10 years behind. And he had to wait 3 months to have it done, so he 3 months to wait before the surgery then 3 more on crutches.
I have heard similar tales from folks that have moved here from Canada. These kinds of new procedures typically are developed in America and spread from here, though they apparently spread slowly to some countries. Why? Because here there is a payback for new procedures that are less painful, faster, and that return you to full productivity both without a long wait and with faster recovery. Yet none of this would show up in longevity. Is it better?
I don't think we have the right measures to evaluate it. The European approach appears to cost less, but doesn't the loss of 6 months of full productivity have a cost, in this example? The newer method may cost more at first, but does the improved quality of life have a value as well as the improved productivity by less lost time from the job, etc?
Someone has said (Churchill maybe?)that capitalism is the unequal sharing of prosperity and socialism is the equal sharing of misery. That comes close. In this case I think there is also something to be said about freedom having costs as well as benefits. Freedom is risky: this was true in the Garden of Eden, but God considered freedom to be worth the risk, even knowing it would result in the crucifixion of His Son. Freedom is highly valued in the U.S. despite its risk and its cost. In this example, when my friend returned home from Europe he met another athlete in a leg brace with crutches. The arthroscopic surgery was available, but he had no insurance and did not have the funds available just then to pay for it.
My opinion is that the U.S. has the best procedures in the world available, and with the least wait. That does not affect longevity outcomes for a variety of reasons, most of them having to do with diet, obesity, and overall sedentary lifestyles. The U.S. also has the most expensive healthcare in the world, pricing some folks out of the market. A better balance is needed: neither a move to be like Europe and abandon innovation and short waits, nor keeping the current situation. I don't think the current legislation does what is needed; I hope it can cause enough debate to get us on a better path.
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3 comments:
You make a very good point about incentives for innovation. I too hope that our current situation will eventually lead to a better balance between innovation and availability.
Daniel says (part 1): You're right to point out that using life expectancy as the only standard for the "quality" of healthcare is flawed. Not only is life expectancy adversely affected by things like sedentary lifestyles and poor diets (which you mentioned), it is also hurt in America by our high rate of violent crime/murder compared to western European countries. All of these factors are certainly bad in their own right, but it isn't really fair to blame the medical system for them, and that is implicitly what we do when we use life expectancy as the only measurement of the quality of our healthcare.
I think you have uncovered the heart of much of the debate. (When I say "debate," I'm referring to intelligent conversations about healthcare issues, as opposed to the overheated political rhetoric and posturing that too often passes for debate these days...) The central ideological issue is this: what do we value most when it comes to the distribution of scarce resources? The political left stresses the importance of sharing resources: protecting the weak and the vulnerable, promoting "equity" and "social justice," ensuring that all members of the community benefit from economic progress. The political right emphasizes issues of individual "freedom" and "liberty": freedom to succeed (and fail), the benefits of innovation and competition, the rights of people to be rewarded for their hard work and success.
Most people would agree that both sets of goals have value. Most of us, of course, have a predilection for one side or the other, but it is foolishness to brand the other side as entirely wrong or malevolent.
I tend to lean to the right, and I think competition and the freedom to fail gives people great incentives to work harder and innovate more than they otherwise would. But I was reminded last night, as I watched the first of Ken Burns' National Parks DVDs, how thankful I am that some things are not privately managed. The movie talked about the way that Niagara Falls, that glorious, majestic, wonder of nature, was turned into a cheap tourist trap by entrepreneurs looking to make a buck by building right up to the edge of the falls. Of profit seekers buying up all the good viewing locations and charging people for the privilege of enjoying God's creation. And, of course, it didn't stop at Niagara Falls. Preserving each one of the national parks was a fight against some vested interest. And the government agents in charge of the parks did lots of stupid things too, especially in the early days. Entrusting our treasures to the government's care is no guarantee that they will be kept safe or well-managed. But at least the parks remained a treasure for the nation as a whole, not just for the privileged elite who could afford to buy them up and wall them off. And the enjoyment of future generations was not sacrificed to the pecuniary gains of the present. The parks are "public goods," as economists call them -- they benefit everyone but would not be produced in sufficient quantities by private enterprise because of the diffuse benefits and the danger of free riders. I am made richer by Yosemite National Park, even though I have never been there. Even seeing pictures of it is sublime, and it gives me pleasure to know that someday, I may be able to walk its trails and that it will still be there for me. I am ever so thankful that I, that we all, get to share the national parks together.
Part 2 from Daniel: Which leads me back to the basic dillemna: to what extent is healthcare a "public good?" America's treasures are not confined to the picturesque landscapes of our national parks; they include the talents, the skills, the inventiveness, the wealth of her people. We long ago decided that basic education was a public good -- that it benefits our entire society to have children receive elementary (and later, secondary) schooling. It keeps them out of trouble, it makes them better citizens, it enhances the economic growth of the nation. All of those things are good for the country as a whole, not just for the individual children themselves. That is why we all pay for public education.
Doesn't the same "public good" argument apply to basic healthcare? Disease and low life expectancies end up affecting all of society, not just the individuals who suffer from them. Health problems affect families, they affect the fabric of sooiety, they affect the entire economy. Think of the HIV epidemic in sub-Saharan Africa. It is not just those with the disease who are hurt. Children are prematurely orphaned. The contributions that those people would have made to society are lost. "No man is an island ... Do not send to know for whom the bell tolls; it tolls for thee." The immediate family, and eventually, the society as a whole ends up losing when people prematurely die. We do not live to ourselves alone, and we do not die to ourselves alone.
But in the same way there are limits to publicly provided "basic" education, there are and must be limits to publicly-provided healthcare, if for no other reason than our inability to afford unlimited quantities of either. (Not to mention the problem of decreasing marginal benefits and increasing marginal costs.) But what are the limits of "basic?" I don't know. But my gut is that it should be more than emergency room care if you are about to die. Then again, neither do I think it's a problem that people on public healthcare should have to wait longer for delayable surgeries, or not have as many choices of doctors, or not receive the newest, most innovative (and expensive) types of care. I guess now that the health care bill has passed, we'll have the pleasure of fighting about all those details for years to come
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