Friday, April 24, 2009

Gratzer on Socialism and Cancer

David Gratzer, MD, discusses some of the flawed comparisons between health care in the US and other countries in this essay from the Winter 2009 issue of The New Atlantic, "Socialism and Cancer".

Here are a few excerpts:
...In a 2000 assessment of the world’s health systems, the World Health Organization (WHO) ranked the U.S. system thirty-seventh -- lower than even that of Colombia. In Sicko, Michael Moore’s 2007 documentary comparing health care systems, the U.S. system is portrayed as broken and cruel. A Commonwealth Fund study published in early 2008 surveyed nineteen nations in terms of preventable death and ranked the United States last.

This unrelenting stream of negativity has shaped the debate over U.S. health care reform. Consumers are souring on U.S. health care; policymakers are weighing the political and economic costs of changes to the system; and, according to one recent poll, even doctors—historically the most vocal opponents of socialized medicine—now support the idea of government-run health care.

...Ask yourself a simple question: If your daughter had a bad cough, would you call your pediatrician -- or get her on a flight to Bogota, Colombia?

While international comparisons make for good headlines and moving speeches -- Democrats, in particular, like to cite the WHO findings on the stump -- these studies are frequently quite limited and flawed. Most of the work is either highly ideological (Michael Moore's cannot withstand a basic fact-check) or confuses health with health care (the Commonwealth Fund study reflects the fact that Americans smoke more and exercise less than citizens in many other Western countries). The WHO study -- intolerant of any patient-borne expenses, heavily rewarding "equity," and focusing on smoking rates and other public health measures—suffers from both these problems of ideology and confusion. That is how it could reach the conclusion that America's health care lags behind Colombia's -- a conclusion no patient or doctor would second with his feet. (And indeed, even the WHO study had to concede that the American health care system was more responsive to citizens' expectations than any other nation's system.)
Gratzer correctly argues that one should analyze how well a country's health system does once people actually become ill, and he uses cancer diagnosis and treatment as one measure, because we have good comparative data on this set of diseases:
Of course, there is more to health care than a response to one disease -- yet, with the focus of so many governments on cancer care, with the common nature of this illness, and with the excellent statistics available, it's fair to use it as a proxy for health care performance. How does the United States fare? Excellently, two major studies suggest.

...Looking at specific cancers yields striking results: For men, the bladder cancer survival rate in the United States is 15 percent higher than the European average. With prostate cancer, the gap is even larger: 28 percent. For American women, the uterine cancer survival rate is 5 percent higher than the European average; for breast cancer, it is 14 percent higher. The United States has survival rates of 90 percent or higher for five cancers (skin melanoma, breast, prostate, thyroid, and testicular), but there is only one cancer for which the European survival rate reaches 90 percent (testicular). Lung cancer, once considered a death sentence, now has better survival rates over five years -- and Americans do better than Europeans, 16 percent versus 11 percent.
He also discusses some of the controversy over prostate cancer statistics.

He then discusses the reasons for these differences:
Why then is the United States better in overall survival? There are several contributing factors. Certainly the ability of cancer patients to get access to new medicines is helpful.

...And socialized health care systems don't just lag on cancer drugs -- new technologies, too, are less available. The problem is well illustrated by the story of Deb Maskens, a mother of two young children who suffers from kidney cancer...

Government-managed and -funded health care systems are not simply averse to new drugs and technologies. These systems are often plagued by rationing through waiting. People wait for diagnostic tests and specialist consults, delays that allow cancers to grow and spread. The diagnostic gap is well documented...
And he offers some concluding thoughts:
Government-run health care systems control costs by rationing care. In contrast, for all its flaws, the American health care system does not hesitate to spend, eager to embrace new technologies and treatments. And that’s why Americans do so much better.

...Cancer care in London or Paris may not seem relevant to Americans in Las Vegas or Providence. But in the coming years, Americans will need to think very hard about their health care system. With a Democratic-controlled Congress and White House, the forces are aligned for far greater government involvement. This does not bode well: value in health care -- as in the other five-sixths of the economy -- will come from competition and choice, not a government committee.

...That is why American health care reform demands an American-made solution, one that respects the power of markets and competition instead of putting trust in government bureaucrats.
Overall, he makes many arguments that politicians should heed.

Anyone interested in more discussion along these lines can find it in his book, "The Cure: How Capitalism Can Save American Health Care" (now in paperback.)