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Her Majesty’s Healthy Service

Her Majesty’s Healthy Service

I was born a Brit but I moved to America in my mid-20s, fell in love with the sun and the fun in California, and never plan on going back. This apparently is bad for my health. On the other hand, perhaps I should move to Canada. Yup, both the Brits and the Canadians apparently are healthier than Americans.
I know this is true because in the last few weeks a couple of separate studies have said so, and even Spot-on‘s editor Chris Nolan has noticed (and insisted I write about it!). The first was a very authoritative research tour de force from the RAND corporation. It compared the health status of Brits and Americans, and it corrected for the imbalance in racial/ethnic make-ups. This gave lie to the line that American health outcomes are bad because we have so many brown and black people with bad habits like shooting each other and getting pregnant without stable families. That’s a line heard frequently from many on the right who love to irrationally bash Canada’s health system and its quasi-racist nonsense in any case, because it implies that it’s color rather than social status that leads to that type of behavior. But if you take minorities out of the equation it turns out that even the poorest white Brits are in better health than the richest white Americans. This has raised some more dispassionate observers to ask what we’re getting for all that extra money we’re spending–after all America spends roughly double the share of GDP on health care than the Brits do and our GDP per head is much higher.

Meanwhile the pro-single payer crowd, led by Steffie Wollhandler and David Himmelstein at Harvard have their own study out which shows that Canadians are also healthier than Americans. Now these guys definitely have a political agenda unlike (ostensibly) RAND–we won’t wade into the Chomskyite waters of whether a major research organization that gets its money from industry and defense sources is “objective”. But the Harvard study shows pretty plainly that Canadians have better access to doctors, preventative care and all the good stuff that keeps one healthy, and that they are healthier, not as fat, less sedentary, and have lower rates of diabetes and high blood pressure to boot. Even though Canadians smoke more than Americans. The Brits (of course!) smoke and drink a lot more.

So Steffie and David leap to the conclusion that the one thing (the lack of universal insurance) leads to the other (poor health). It’s not the first time that they’ve done that recently, and they were called out on a study Himmelstein did about the impact of medical care costs on bankruptcies by a couple of NorthWestern researchers who say that they misinterpreted /fudged/lied about their own data. (And they called out the Northwestern guys in turn, partially because their research was funded by the health insurers’ lobbying group).

But are they right to say that universal care insurance improves health status? Not too surprisingly James Smith, who led the RAND study, doesn’t think that insurance coverage makes too much difference. In his study the insured Americans did worse than the Brits, who are all insured but presumably have worse access to care than most insured Americans–you’ve all heard about those terrible NHS waiting lists haven’t you?
So what’s really going on here. Well a brief trip to Health Econ 101 will help out. Stanford Econ professor Vic Fuchs (who basically invented health economics as a field) used to tell the story of how in the US in World War II most doctors were pressed into the army and many people found their access to medical care dramatically reduced. Health status in the population actually improved.
This makes the wider point. Essentially there is almost no connection between the health care system and health. Sure particular spot interventions can make a big difference. My snowboarding career only continues because of some skilfull, and damn expensive, surgery post my knee-tree contact technique (guess who won that!). England’s World Cup chances depend largely on the speed of the repair to Wayne Rooney’s metatarsal bones, apparently aided by Oxygen tents and all manner of care I bet he’s not getting gratis from the U.K.’s National Health Service. But in general, the link between medical care and the most visible measures of overall health such as life expectancy and infant mortality are very tenuous. It’s actually things like eating well, vaccinations, and clean drinking water that make the difference.
Medical care delivery is largely a result of cultural and economic factors. It’s just not in any way designed to promote overall community or national health–especially not in a country like the US where we just don’t do central planning of anything (not even for foreign wars or hurricane relief). So in general I think that academically Steffie and David are pissing into the wind when they say that Canadians are healthier because of their system.
But there is more to it than that. The differences between being a better-off and worse-off American are pretty stark, and they are clearly magnified by access to health insurance, even if those differences don’t always translate immediately to health outcomes.
In fact the Institute of Medicine estimates that delays in accessing preventative care services caused by uninsurance caused roughly 18,000 premature deaths annually. So you can argue that there is a connection between the system and the outcomes. But to me it’s a little nebulous. However, we’re Americans which means that there’s something more important than death (especially someone else’s death), and that’s money.
As above the chart from a 2000 Newshour survey shows, being uninsured means that lots of people don’t get care that at least they think they need. And that old Democratic war-horse Ted Kennedy has got it almost right when he says that the answer is:

Medicare for All, because it will free all Americans from the fear of crippling medical expenses and enable them to seek the best possible care when illness strikes.

The truth is that poorer Americans do indeed suffer in the current health care system and their suffering is more financial than health related. Several studies over time have shown that Americans have far higher out of pocket costs than any other developed country, and that those costs are unequally distributed on the poorer and sicker among us. And that ignores the considerable psychic costs that come from worrying about access to health insurance and medical care, and the considerable financial costs that the complexity of administering a broken health system puts on the nation.
The goal of a health care system should not be to make us healthy, nice though that would be. Neither should it be to get us to the best possible care when illness strikes because we’re never going to agree on what best is. But it should be to free us from the incredibly unpleasant fact that illness will cause crippling expenses.
And that’s something that political changes can, and hopefully eventually will, achieve. As for making us healthier than the Brits and the Canucks, well that’s a much more intractable problem.