Tuesday, July 31, 2007

Take a pill

Here's a health care horror story:

Mountain-bike enthusiast Suzanne Aucoin had to fight more than her Stage IV colon cancer. Her doctor suggested Erbitux—a proven cancer drug that targets cancer cells exclusively, unlike conventional chemotherapies that more crudely kill all fast-growing cells in the body—and Aucoin went to a clinic to begin treatment. But if Erbitux offered hope, Aucoin’s insurance didn’t: she received one inscrutable form letter after another, rejecting her claim for reimbursement.

Ms. Aucoin's story wasn't included by Michael Moore in Sicko. It hasn't been told by Sen. Kathleen Vinehout or other state Democrats pushing their new health plan. You'll never hear about it from Nancy Pelosi or Ted Kennedy.

Why not?

Because Ms. Aucoin lives in Ontario, Canada. Her clinic was in Buffalo, New York. There's an inconvenient truth for you.

Dr. David Gratzer in the City Journal discusses this and other difficulties with the Canadian health care system. He might have added that the Canadian Supreme Court found that wait times for surgery in Quebec combined with a ban on private care were a human rights violation.

The large truth here is that there is no such thing as unlimited care. Canada needs to hold down its health care expenditures just as everyone else and, as a consequence, the government becomes one large HMO.

Gratzer's piece did not answer all of my questions but made four points that are worth keeping in mind.

1. There is a free rider problem here. We go into high dudgeon over the fact that American-made drugs are sold less expensively in Canada (where there are price controls) than they are here. Bad greedy drug companies.

But we don't stop to acknowledge that these things are invented in New Jersey and not New Brunswick. This may have something to do with the financial incentives for development that exist here and do not exist in Canada. The cost that must be recouped for drugs is not the cost of stamping them out (much like software, that's minimal), it's in inventing them.

The fact is that an outsized share of medical innovation happens in the US with its "uniquely horrible" health care system. Maybe that's just God's practical joke. Or maybe not.

(Yeah, I know drug companies spend a lot on advertising but that's a function of choice, no?)

2. Health care is better in the US. The argument that it is not is generally based on what Gratzer calls crude indicia of health (as opposed, say, to the outcomes of medical treatment). He writes:

But such outcomes reflect a mosaic of factors, such as diet, lifestyle, drug use, and cultural values. It pains me as a doctor to say this, but health care is just one factor in health. Americans live 75.3 years on average, fewer than Canadians (77.3) or the French (76.6) or the citizens of any Western European nation save Portugal. Health care influences life expectancy, of course. But a life can end because of a murder, a fall, or a car accident. Such factors aren’t academic—homicide rates in the United States are much higher than in other countries (eight times higher than in France, for instance). In The Business of Health, Robert Ohsfeldt and John Schneider factor out intentional and unintentional injuries from life-expectancy statistics and find that Americans who don’t die in car crashes or homicides outlive people in any other Western country. (emphasis supplied.)

This may be why Americans report a high degree of satisfaction with their care, if not their insurers.

3. Other countries are moving away from state directed health care, gradually privatizing what was once state provided care and slowly asking their citizens to assume more responsibility for their own care.

4. The notion that the US pays too much for health care is not evidently correct. The US is a very wealthy country. As national wealth increases, what people spend money on is likely to change. I can only eat so much or wear so many clothes. I might decide, as I grow wealthier, to buy more health care and, as I do, this health care is probably going to be concentrated on the treatment of formerly fatal conditions that are both infrequent and, probably, concentrated among older populations. Thus the US, for its extra money, becomes very good at treating very sick people.

All of this underscores something that we should not lose sight of. Michael Moore is flat out wrong. We have an extremely good health care system here. We have, it is true, a need to reform the way in which it is paid for - a need on which conservatives and liberals agree, even if their proposed reforms are very different.

But in discussing reform, we should not treat the system as a given, unaffected by the way in which we pay for it. We should not throw out the baby with the bath water.


illusory tenant said...

He might have added that the Canadian Supreme Court found that wait times for surgery in Quebec combined with a ban on private care were a human rights violation.

Keep reading your own link. He did. He also takes care to distinguish Quebec's Charter of Rights and Freedoms from the national one, which you didn't.

The Chaoulli majority did not find Quebec's practice violative of the latter.

Anonymous said...

Speaking of throwing out babies -- if our system is so great, why do we have such a high infant mortality rate? (The so-called prolifers could save more babies by improving that.)

The U.S. excels at keeping the aged alive to age even longer, while babies die. Interesting priorities. in this allegedly excellent system.

Rick Esenberg said...

The Chaoulli majority did not find Quebec's practice violative of the latter.

No, I was aware of that. You made a big point of it recently on your blog or somewhere, but I don't regard it as significant to the point that I was making (i.e., people wait a long time) so I didn't mention it.

I stand corrected on your other point. I had read it last night and forgot that.

As to infant mortality rates, I can think of all sorts of reasons that have nothing to do with the quality of available care. Or, for that matter, it's availability.

illusory tenant said...

I made a small point of it in, I think it was, folkbum's comments section, in response to somebody's outlandish claim that Chaouilli is the harbinger of Canada's rapid ascent (or descent, depending on your perspective) into private health care.

Nevertheless, it's an important point.

While it remains to be seen, Chaoulli is at least as likely to bring about improvements in the existing system as it is to birth a regime of recalcitrant HMOs.

As for the "horror story," OHIP doesn't cover out-of-country medical expenses, so it's not all that surprising that Ms. Aucoin endured a (successful) struggle getting reimbursed.

Rick Esenberg said...

As for the "horror story," OHIP doesn't cover out-of-country medical expenses, so it's not all that surprising that Ms. Aucoin endured a (successful) struggle getting reimbursed.

But the point is that she had to go to Buffalo to get this treatment put on the table and was denied it in Canada again and again until she finally obtained relief.

The point is that claiming that something is "free" or "universal" or that there is "no profit" does not resolve all problems and can create some new ones.

Anonymous said...

Isn't the treatment she recieved in the US at best experimental?

There is no magic pill to cure cancer and to lead people to think there is is irresponsible.

People from the US go to other countries for cancer care, as well.

Anonymous said...

Part of the reason for the high infant mortality rate is the refusal of young women to follow through with prenatal care that is available to them. In addition, the use of drugs while pregnant.
I used to work OB and saw some awful things.

Anonymous said...

You state that we have a very good health system but you don't really say what you base that on.

Do you have personal experience or know someone that has. Did you get something fixed here that can't be fixed anywhere else in the world. I do not know what that would be.

What does the US health care system do that is supposed to be worth so much more? People are still dying of cancer, staff infections, and many other diseases.

You say Fiengold makes broad statements regarding Bush (and he is)but here you are doing the same thing.

Anonymous said...

Rick and Illusory, indulge me if you will. If the treatment was available in Canada, she wouldn't have gone to Buffalo to obtain it.
So it's not "out of country" costs that Canada is denying. Canada doesn't offer the service that she wants and needs. Illusory, you note that after a struggle she was reimbursed. That's nice. Why couldn't her country provide the service that she found in America??
How many other patients with other maladies are dead, dying or crying right now, because of socialist principles that are dis-insentives to medical progress and choices. I guess the point as I see it is.....Canada couldn't help her. If we were to follow Canada's failed (IMHO) model, where do I go to get a treatment that both Canada and America won't provide???
Let me guess??? Mexico?? Nope, they're coming her too.
Illusory, can you tell me of any Americans that seek out Canada for treatments they cannot get here?
Again, (IMHO) this is about socialism and control, not about the health care options of America.

Anonymous said...

I think Benjamin Disraeli said, "It is easier to be critical than correct."

From what I've heard, Sicko criticizes much and solves little. I'm sure it is annoying and unpersuasive.

But, Rick, even Milton Friedman admits that the current system is problematic...largely on account of market failures inherent in the delivery of health care.

And they don't get much more libertarian than Friedman!

Billiam said...

I've never had a problem with Health Care. I have, as have friends, had all kinds of problems with INSURANCE. My insurance will only pay $10.00 towards Nexium, the only thing that has given me relief from reflux. Since I can't afford the $90.00 a month that it would cost me, I deal with the pain. Again, it's available, but insurance won't pay as they say they don't cover "New" drugs.

Anonymous said...

libocrat said...

"Again, (IMHO) this is about socialism and control, not about the health care options of America."

Right now we have no control over health care costs, no control over insurance costs and coverage, people can't change jobs because of pre-existing conditions, your employer can fire you and drop your insurance if you start having medical problems and there is nothing you can do about it and you can lose everything you worked hard for including your house to the medical industry.

You may like where the control and power is now, but people that have experienced it or those that have perception of what monopoly does to people want a change.

Dad29 said...

Seems as though some critics of the existing system wish to believe that 'all' can be cured by going state-health-care.

I've conducted a study, too.

And I guarantee you that every human that is born WILL die, sooner or later.

Maybe cancer, maybe heart attack, maybe a seriously-unhappy spouse.

Our problem, as GKChesterton said, is that some have proposed the superlative without having defined the comparative.

Anonymous said...

dad29 - what would be the drawbacks of universal healthcare? (Actual stories from countries that have it or your best hypothetical scenrio).

I'll compare them to people I know in Sweden and to those I know in this country.

One thing this country should have is a place that people can lodge the complaints they have that can be seen by all people.

Rick Esenberg said...

Joe C.

Well put. I agree that there are all sorts of problems with the status quo. By the way, don't make too many plans for the weekend before classes start. You'll be reading.

Anon 6:48 wrote:

Right now we have no control over health care costs, no control over insurance costs and coverage, people can't change jobs because of pre-existing conditions, your employer can fire you and drop your insurance if you start having medical problems and there is nothing you can do about it and you can lose everything you worked hard for including your house to the medical industry.

You absolutely can change jobs and retain coverage for pre-existing conditions at least as long as you've been covered in an ERISA qualified plan. Your employer absolutely cannot fire you because you have made health claims.

"We" do have control over health care costs. "You" don't (or I don't) because you (and I) aren't paying for it. In almost all cases, the mean "insurance company" (actually its more likely an administrator) is actually acting to control costs. If you think that there won't be people with a similar function under a single payer plan, you are sadly mistaken. Much the same observation applies to Billiam and his insurer's refusal to cover Nexium.

Anon 4:46 wonders why I say the US system is better. Read the quote and follow the links. We have an accessibility and payment problem. We do not have a quality of care problem.

Anonymous said...

Rick - its hogwash that your employer can't fire you for health claims. They can fire you for whatever they want to because we are a right to work state. They can say whatever they want to fire you.

You have no control over health cost and neither does your adminstrator. Companies are trying all kinds of ways to escape the high costs but the medical industry just keeps charging whatever they want without control or worry of not being paid or under bid. The high costs is what your insuarnce costs are based on.

Regarding quality, I went in for a surgery that was to last for 1 1/2 hours. They never told my spouse anything until they brought me out seven hours later. Needless to say I was in worse shape then when I went in and we couldn't get them to do anything about it. They released me as if everything went fine when I hardly could walk, see talk and had to fight for every breath I took.

A couple days later another doctor told me after finding somethings wrong that he was surprised I was alive. He wanted the file but it was a terrible drawn out problem and when we finally got some most was missing.

You say medical malpractice? Hogwash - thats also prearranged in the medical industries favor.

That is only one story and there are more serious ones that I could share. By the way, the doctor used was one of the two best in his field in the Milwaukee area. I now have a different difinition for what the best means.

The reality is different from the la la land that the industry wants you to believe. I was also fired when we reported that the surgery didn't go well. No fault they said.

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