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April 20, 2005


John  Fembup

Here are some data recently published by the Centers for Medicare and Medicaid Services in the US. The source is OECD. These are the average annual rates of growth in per-capita health care spending over the entire decade of the 1990's in the followng countries:

Canada 4.2%
France 4.4
USA 5.3
Germany 5.5
Australia 5.9
Switz. 5.9
Japan 6.1
Austria 6.1
UK 6.2
Belgium 6.2
Spain 6.8

This is over a ten-year period folks. The US is NOT the highest or even in the top 5. The US is 9th. NINTH. Does this demonstrate a clear advantage that national, single-payer systems have in controlling the growth of health expenditures? I think not.

One by one the health care "utopias" advanced by single payer advocates as examples of the superiority of that strategy in other countries, have unraveled. First in UK, then Canada. Now Germany, France and the Scandinavian countries are teetering, and others are finding themselves neck deep in their own cost crises. Netherlands, Belgium, NOrway, and so it goes. Have all the industrialized nations of the world except for the USA truly "solved" their health care problems? I think the answer is obvious - they have not.


Is this comment a joke? John, you cherry pick like an insurance company. Where to begin...oh, the obvious! From 1990-2000, the population of Americans over the age of 65 DECLINED from 12.6 to 12.4%, while in Europe, those numbers generally increased (though in some countries they remained flat). To pick two--Germany saw a jump in its population over age 65 from 14.9% to 17.8%, and Belgium jumped from 15% to 17.2%. Here's a third--France, which saw SLOWER growth in helathcare spending than did the US, also saw its over 65 population share jump over 2% higher.

You may be unaware of the causal connection between a nation getting older, getting sicker, and spending more on healthcare--but trust me when I say the data is incontrovertible. So, in a decade where Europe gets older, its growth in health spending is on par with a decade in America that sees a decline in the number of American seniors? And you don't even mention the effect the HillaryCare scare might have had on the industry, as well as the impact managed care did? You suggest we should be comforted when in an optimal climate for cost control we are barely containing our growth to approach European rates? Because I'm not comforted. At all.

No sensible person thinks single payer will "solve" all our healthcare system's problems, and no one who's been in health policy for more than 10 minutes thinks they'll ever live to see the promised land, much less a utopia.

What we are saying, over and over again, is that if you want to spend less and get more then single payer is an excellent, proven approach (you duplicitous jerkwad). Well, probably just I'm calling you a duplicitous jerkwad.

John Fembup

"if you want to spend less and get more then single payer is an excellent, proven approach (you duplicitous jerkwad)"

Well, you have certainly raised the level of the conversation. And you ask if MY post was a joke? Usually one must go to a bowling alley to enjoy your idea of witty repartee. Thank you for your response.

But back to my bowl of cherries.

If a government single payer mechanism will truly "spend less and get more" then one can expect the per capita spending for the US Medicare population is roughly the same as the over-65 population in say, France. OECD again:

US per capita spending by age group - 1999
19-44 = $2,500
45-54 = $4,000
55-64 = $5,000
65-74 = $8,000

France per capita spending by age group- 2000
30 = 1,100 Euro ($1,500)
40 = 1,200 Euro ($1,600)
50 = 1,600 Euro ($2,100)
60 = 2,500 Euro ($3,300)
70 = 3,600 Euro ($4,800)

Spending for the non-Medicare population is as expected much more in the US than in France. But spending for the over-65 population is also much more. A single payer effect is not apparent. Medicare as a single-payer does not achieve results anywhere close to the French expenditure level for a corresponding, over-65 population. Well why not? Do Americans simply demand more services regardless who pays? Would a single payer mechanism extended to the rest of our population do any better than Medicare?

If a single-payer elephant is in our refrigerator, her footprints will certainly be in the jello. I don't see them.

Stirling Newberry

Well lying is never a good way to help your cause - US health care grew at a 5% rate between 1993 and 1999, and its percentage of GDP stabilized. But much of this was at the cost of lower heatlh care delivery through managed care, not because of real efficiencies. Once that temporary market glut was removed, health care costs in the US started to march up again. Over the period 1960 to 2004, health care has moved from 5% of GDP to 14.4 percent in 2001. Some projections put it at 18.3% of GDP by 2013.

The other lie in your figure is that you neglected to point out that all of the other countries were spending far less per person than the US is. In fact, the closest cost per capita among the countries listed is 70% of the US. That means that the same size increases in cost show up as larger percentages, because the base of the others is smaller.

Another lie in your comment is that you neglect to mention what the US is getting for its money - it ranks, by far, at the bottom of most measures of health care. To say that we are spending more and getting less, but that if we have 4 1990's style booms back to back the rest of the world will be even with us, is not an argument that has any economic plausibility.

What it looks like is that you got your screaming point from the RNC, came in, lied to people to spread it, and are now getting huffy because you don't like people telling the truth about your being a liar.

So you come in, insult people's intelligence by lying, and then get all butter won't melt in your mouth when people get angry.

Stirling Newberry

Oh and another lie:

"A single payer effect is not apparent."

France doesn't have a single payer system...

Just for the record.

John Fembup

Good point about France. Just goes to show what the average person in the US may know - or not know as the case may be.

But . . . accusing a person of "lying" does not prove lying, any more than saying that single-payer systems are an excellent, proven approach demonstrates their excellence or constitutes any proof at all. Saying a thing and making a logical and fact-based argument for the thing are different. I don't think you have provided the logical linkage between your "ifs" and your "thens", but of course I don't know it all (see "France", above), and you have not exactly devoted all your attention to persuasion.

What does the excellence of single-payer consist of? How do we know when we see it?

Any reasonable definition of single-payer effects that anyone wants to use will be OK - Newberry seems suggests it's more health care services, delivered at much lower cost, accompanied by significantly improved measures of health. Fine, those are the single-payer effects. That's what we are looking for. Surely everyone agrees that these are worthy goals?

Now, where is the evidence of these single-payer effects within single-payer systems? If the beneficial effects of a single-payer mechanism are so subtle that they can't be shown, then what is the point? But if the effects are undeniable, then where are they? Based on the emotion this matter generated, I'd expect oceans of undeniable evidence. Medicare is a single-payer system for the over-65 population in the US. Does Medicare deliver more services to its population? Does Medicare deliver its services at much lower cost? Is the Medicare population in much better general health than other populations of similar age? If not, why not? Why wouldn't the beneficial effects of the single-payer system be undeniably present in Medicare? Would a single payer mechanism extended to the rest of our population do any better than it is apparently doing for Medicare?

You clearly do not like it, but I think those are serious questions. And I think I'm not alone in asking them.


Ah, the bowling alley invective was a bit strong. But so many of us healthcare wonks and wanna-bes grew up on the mean streets and picked up our mad debate skillz where we could get 'em. Today, you'll find us bowling alley debaters lurking about in blog comments sections. I think the smell reminds us of the shoes...

But I stand by my point. John puts together a roundup of the debate generated by cross-cultural comparisons, points out some of the key issues that aren't being talked about, and your response is to...cite a single stat and use it to argue that all systems are facing the same crisis.

Well, as my ten-pin gang would say, that's a gutterball. All healthcare systems face lots of problems (plural, not singular) because it turns out that healthcare isn't easy. Shocking, I know. The US has the same problems everyone else has, and we also have a few problems they don't. Only in the US do people worry about going bankrupt if they get sick. In the US, fathers wonder how they're going to get their little girl's asthma medication after the factory closes next month. Our public health officials worry about our response to a bioterror attack being delayed because uninsured folks will delay getting care. In the US, the richest nation on Earth, people suffer and die because they can't afford to pay for care. This is a great source of agitation to many Americans--motivated by personal fear, human compassion, and arguments of economic efficiency. And in addition, in the US we spend more money on payment/insurance administration than other nations do. Interestingly, we only have these high administrative costs in the non-universal part of our system.

You, on the other hand, open up your argument by citing a cherry-picked stat. You accuse smart people of making stupid arguments that they simply haven't (the UK is "utopia?"), and you use your little stat to draw a conclusion that it doesn't support--namely, that the crises faced in the US healthare system are the same as those faced in other systems. Among people who actually know the facts, this earns you no respect.

You then get defensive about being harshly judged, implicitly accuse your detractors of a lack of seriousness and suggest that serious people should instead be investigating questions like "what does the excellence of single payer consist of," and that to really prove their argument, they should compare the health of the Medicare population to "other populations of a similar age." Of course, notwithstanding the fact that some of your questions are unanswerable as posed (um, how do you get a comparison population of "similar age" to Medicare who aren't on Medicare when Medicare is an age-based program? That's like trying to compare "normal" short children to "normal" 6 foot children to determine the impact that a parent's coaching has on basketball skills. You're really not studying what you think you are), it's obvious they're not really questions at all but attempts to look "serious" while ducking the implications of all known facts about the impact single payer systems have on access to care and administrative spending.

Maybe you've been in a hole, but there ARE oceans of evidence. Turns out that, all other things being equal, single payer/universal healthcare systems don't generate the same administrative expense (even in our system) and they decrease financial barriers to accessing healthcare. It also turns out that it doesn't solve all a healthcare system's problems, and that there are other very important things we should also be doing to improve the system (e.g.: data digitization and transfer, quality improvement, practice variations, reforming physician education, rural/urban supply, fraud, liability, end of life care, etc). Furthermore, there's evidence that dealing with a number of these problems will be easier in a universal system than in ours--although I can imagine that a few of them will be harder (although, honestly, I can't think of them offhand).

Listen, I'm sorry if you're ideologically opposed to single payer/universal health care. I'm sorry if you think it will lead to catastrophe. But frankly, the data doesn't support your position. And at the end of the day, I think serious people would agree that it's more important to make our policy decisions based on what we reasonably think will occur as a consequence of them (as informed by experience and fact, domestic and cross-cultural), and not doomsday scenarios of what "should" happen based on one's ideological leanings.

Unspoken in all your comments is the fact that the status quo has a body count and it's going up. We don't have the luxury of indulging our ideologies or fears anymore.

Here endeth the rant. I'm going bowling.

John Fembup

I regret that I'm neither as smart or as informed as you - or your circle. I am a bit wiser now however.

Have a pleasant day.

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