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Scream this from the rooftops, a continuing series
Indeed, the health-income gradient is slightly steeper in Canada than it is in the U.S.
Here is the paper (can anyone find a non-gated version?), which offers many other interesting points of comparison between the two systems. Here are previous installments in the series.
Posted by Tyler Cowen on September 22, 2007 at 07:35 AM in Medicine | Permalink
Comments
another couple key sentences:
"The U.S. health care system is often critiqued by noting that health expenditures in the U.S. are the highest among the OECD countries---twice as high on a per capita basis as Canada’s"
and
"Briefly, our findings are: No significant differences are evident in the four health status indicators available in the JCUSH data."
So the Canadian system produces the same results at half the cost and the implicit criticism is that it is not producing better results for half the price, as some claim?
Posted by: Jeff at Sep 22, 2007 10:13:40 AM
I stopped reading after this sentence: “The need to ration resources in Canada, where care is delivered "free", ultimately leads to long waits.”
Anything that is scarce has to be rationed in some way. Market prices are a method of rationing just like line ups. Society uses numerous methods to ration goods (e.g., grades and money for university entrance, severity of illness for emergency rooms,). If the line up is too long, some people will not get the medical attention they need and die—they will be rationed out of the health care system. Similarly, people who do not have enough money to pay for medical attention (i.e., their willingness and/or ability to pay is below the market price) will not get medical attention and die—they too will be rationed out of the health care system. I’m sure more Americans (as a proportion of the population) are rationed out of health care than Canadians.
Posted by: Joe Gideon at Sep 22, 2007 10:24:20 AM
The steeper Canadian health expenditure vs income with respect to the U.S. should be expected given Canada's position with respect to the U.S. on the S-shaped curve that describes the relationship between these two factors - see this graph (from this post).
Posted by: Ironman at Sep 22, 2007 10:58:59 AM
and in fairness, I cannot disagree with, as far as it goes:
"The need to ration when care is delivered “free” ultimately leads to long waits or unavailable services and to unmet needs. In the U.S. costs are more often a source of unmet needs. But costs may be more easily overcome than the absence of services."
Though I would say:
1) When stricken with a medical emergency or serious illness, I suspect most people without the means to pay or insurance find overcoming costs nearly as difficult as finding an absent service.
2) This same paper talks about Canada following the trend in the UK and other countries where private health care is also available. I imagine these private alternatives are probably providing some of the "absent" services. I can't imagine they've sprung up mainly to cut waiting times for redundant services.
and they acknowledge my point from the first post above:
"One important issue that we do not address concerns the large differential in per capita health care expenditures which are about twice as large in the U.S. Is the U.S. getting sufficient additional benefits to justify these greater expenditures and where should we
cut back if cutbacks must be made?"
I sure don't know enough (anything) about regression analysis to know if they have proven their point: that the correlation between health and wealth is as great (or a little greater) than in the US. But as they point out earlier in the paper, when assailing life expectancy and infant mortality as barometers of health care, lifestyle is vital to health too. And money correlates to better nutrition, etc.
If Canada is delivering equivalent results for half the money (as the paper itself says), is their system better? And does anyone know roughly what amount of the difference in cost is due to Canada's status a free rider with pharmaceuticals?
I feel like I have Michael Moore and Milton Friedman perched upon my shoulders.
Is it better to have superior health care abilities, with access restricted according to financial means, or a lower ceiling on ability with access to all?
Posted by: Jeff at Sep 22, 2007 11:02:22 AM
The point is this: you can present a health care plan for greater government involvement and argue: "This will save the United States on the cost side." This claim can then be argued on its merits. But if you argue: "A single payer system will give us fairer health outcomes" -- and yes that is a major, major claim made in these debates -- this result is a big ouch. A big, big ouch. The temptation is to conclude "the Canadian system is still good enough for me" without in the meantime engaging in the necessary revision of beliefs about fairness. The reality is that for most advocates of single-payer systems equity is a major motivation, maybe the major motivation (along with supposedly better outcomes in the absolute sense), and ex post people try to find ways to make it affordable, make up on savings elsewhere (e.g., preventive care), raise taxes, and so on.
Posted by: Tyler Cowen at Sep 22, 2007 11:06:31 AM
Well I find it less than convincing that the same paper at one point attempts to uncouple general health from health care when arguing against infant mortality as a measure of health care results, and then turns right around and uses the correlation between wealth and health as an argument against the Canadian system.
So:"However, both infant mortality and life expectancy are poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care."
Yet it is some kind of discovery to find that "health status" correlates with personal wealth in Canada as well?
And this "health status" is pretty damn fuzzy: it's self reported and limited to poor, fair, very good, and excellent.
Kind of comical to dismiss the relevance of hard life-expectancy numbers and perform regression analysis on tick-box survey results.
If we grant infant mortality and life expectancy are not "fair" data to use in judging health care systems because so many other factors contribute to them besides health care, is it "fair" to expect the Canadian health care system to overcome all the other factors that surely must contribute to "health status" and deliver equal "health status" to citizens of all economic strata?
Posted by: Jeff at Sep 22, 2007 11:42:26 AM
Tyler, can you cite some actual measurement of motivations, or is that just your personal opinion?
My personal motivation is not equity in the sense of fairness or in the sense of equality. It's fear: fear of personally not having access to needed health care for myself. That fear is one thing that drives me to continuous employment, and of course it locks many others with pre-existing conditions into their current employment.
Posted by: Mike Huben at Sep 22, 2007 11:49:05 AM
I'll second Mike's post, I think that fear is a primary motivation.
And I think Tyler may be right in equity being perhaps the main motivation, though I suspect people are looking for equity in access to health care rather than equity in long term "health status."
I do think this paper bolsters a recent post on this blog, though it was by Tabarrok.
And for what it's worth, I am a fan of neither system. I don't know jack about economics really, but I like the sound of the Singapore-style system discussed in Undercover Economist, a couple grand in a tax free health account with last-resort government safety net.
But I'm 2 things:
The kind of jerk who'd screw up the negative income tax system by never working another day in my life. (There's probably more of us than you think.)
The kind of jerk who doesn't know jack about statistics beyond the odds of making an inside straight but suspects regression analysis of 6000 broadly categorized check box surveys are questionable grounds for revising my beliefs, much less framing an important debate.
Posted by: Jeff at Sep 22, 2007 12:07:41 PM
Tyler:"But if you argue: "A single payer system will give us fairer health outcomes" -- and yes that is a major, major claim made in these debates -- this result is a big ouch. A big, big ouch."
Where Michael Moore starts to make sense to me (and he almost never does) is his argument that uninsured people put off visiting a doctor when indicators of serious illness (a lump, for example) appear.
Now will they fall into economic ruin by visiting a doctor to check out a suspicious lump. No. and there are safety nets in place (medicaid, high deductible insurance plans) to protect one if the lump turns out to be cancer.
But that doesn't really matter, because uninsured people put off visiting doctors. And I'm not sure if Tyler's quote above takes this into consideration.
Posted by: thehova at Sep 22, 2007 12:16:09 PM
Not having access to the paper, I wonder if it addresses this: To what extent is the Canadian result due to the ability of wealthier Canadians to avail themselves of options in the US?
If it's a factor, and if we adopted a universal plan in the US, wouldn't that address equity issues on both sides of the border? Sure, it would do so at both ends (increasing care to the poorest, decreasing it to the upper middle class, the very wealthiest can always find another option), but then Hirschman's Voice enters the picture, does it not?
Posted by: Eric H at Sep 22, 2007 1:47:03 PM
Liberal MP doesnt think like the the people commenting here:
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20070914/belinda_Stronach_070914/20070914?hub=Health
Posted by: juancarlos at Sep 22, 2007 2:13:45 PM
if you live in a third world country like i do , you can read non gated version of the paper.
Posted by: juancarlos at Sep 22, 2007 2:16:29 PM
Tyler, among all the blather in my previous posts I have a genuine question:
If infant mortality and life expectancy can be dismissed by the authors as methods for judging a health care system because they are affected by many factors other than the system, why is it logically acceptable to then use self-reported, 4-categories-available, "poor/good/very good/or excellent" "health status" as a basis for judging the system, when someone's "health status" has to be subject to other factors as well?
So "health status" is a legitimate variable to compare across socioeconomic strata to judge health care, while life expectancy and infant mortality are dismissed (and in the latter case directly linked to the # of blacks in the US)?
The authors seem to cherry-pick play with their data until they get the result they like.
Is there really no harder data on which to base socioeconomic health care results than regression analysis of a 4-box survey?
Is this study typical of economic research?
It seems very lazy and specious to me.
Posted by: Jeff at Sep 22, 2007 2:28:24 PM
Jeff is right. This paper is about the "self-reported health/income" gradient, not the health income gradient.
Posted by: dsquared at Sep 22, 2007 3:26:39 PM
"A single payer system will give us fairer health outcomes"
I suspect that many people (being one of them) are really thinking
A single payer system will give us fairer access to health services
To be honest, I think process is far more important in most people's mind's than outcome, which is very hard to meaningfully measure in any case.
Posted by: Tom West at Sep 23, 2007 11:59:56 AM
Tyler:
You can download the paper just be entering your gmu email at the bottom of this page: http://www.nber.org/papers/w13429
I am a GMU student and it worked fine for me from home (off campus).
Posted by: Mikra at Sep 23, 2007 5:59:47 PM
"Indeed, the health-income gradient is slightly steeper in Canada than it is in the U.S."
~ Isn't it possible that this just reflects the fact that wealthier people in either country tend to take better care of themselves? It probably has more to do with lifestyle habits. Wealthier people tend to exercise and eat better than the less wealthy. Why this is more true in Canada might be due to any number of factors that don't relate to their national health care system.
Posted by: kvn at Sep 24, 2007 2:26:49 AM
My un-economically-educated reasoning suggests that if this is due to the rich getting better private treatment it surely means that the quality of health care in Canada is inferior.
Imagine if you forced everyone to use the state provided healthcare, then the outcome may be more equal, but the overall quality low. It would bring the quality of care of the rich down rather than the quality for the poor up.
Many who call for economic equality don't care about that (they prefer to hammer the rich - ironically most of these people are fairly rich), but to me that is unethical. If there's a problem with the quality of care for the poor try to raise it rather than lower it.
Posted by: Tristan Mills at Sep 24, 2007 6:11:05 AM
You cannot compare self-reported health (SRH) across two different countries. Even in the US, it has been shown that Hispanics show much lower SRH values than other ethnicities despite having better (or at least as good) health outcomes when measured by more objective variables.
Funny, when they used HUI (a more comparable measure of health) they found "In the HUI regression results the gradient is weaker in Canada than in the US and not statistically significant", but of course they chose not to mention this result in their abstract...
Posted by: Ricardo at Sep 24, 2007 6:25:48 PM
Of course the correlation is higher in Canada - access to better health-care options include travel costs to the United States.
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