Saturday, January 19, 2008

Brain surgery and single payer health care

Here's the future of YOUR health care, folks assuming we aren't smart enough to stop this stuff cold.


  1. Anecdotes are nice (Michael Moore's Sicko contains dozens of similar stories about Americans being denied coverage from private insurance companies). Statistics are better, however.

    Somehow, those dysfunctional Canadians manage to get an infant mortality rate that is 25 percent lower than the U.S. On average, Canadians are also projected to live just over two years longer than U.S. citizens. The Canadians do this despite having a per capita GDP that is 18 percent lower than the U.S. and overall health expenditures that are nearly 50 percent lower than in the U.S.

  2. "Somehow, those dysfunctional Canadians manage to get an infant mortality rate that is 25 percent lower than the U.S."

    Do you know WHY that's the case, Dave?

    (Hint: Check the methodology difference regarding how Canada determines these numbers versus how the US determines them.)

  3. Infant mortality and longevity are measures that are only partially influenced by health care provided. There are also genetic and behavioral contributors. If the Canadian and American populations were the same genetically and also from the standpoint of behavioral risk factors, this would not be an issue. Unfortunately, those populations probably are not comparable, for various reasons.

    Perhaps a better measure is how well patients do with a given health condition once they attempt to enter the system to receive care. I think we would stack up very favorably on this score against the Canadians. In fact, this is probably why they cross our northern border to seek care in the US when they can. I don't see much migration in the opposite direction to seek care.

  4. Bubba:

    If you have a link, please post it. I took the figures from the CIA's World Factbook.


    So Canadians are so genetically and behaviorally superior that they can get better mortality outcomes while being poorer and spending half as much on health care. Interesting.

    As you are surely aware, exactly when you enter the health system makes a big difference too (ounce of prevention and all that).

    Also, people have been traveling to Canada (and Mexico) for cheaper medical treatments and especially for cheaper medicines. You'll recall the drug reimportation debate from a few years ago.

    Canada appears to do a very good job with the basics; the U.S. does a better job with high-end care.

  5. Ah, Dave!

    Always the statistics, without any critical analysis to understand WHY the statistics are the way they are.


    "First, it's shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths.

    In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don't reliably register babies who die within the first 24 hours of birth.

    Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country."

    I can't wait to read your response on this.

    It ought to be interesting to see how you intend to rationalize your personal viewpoint that can't be supported by the facts of the situation.

  6. And then we have this:

    "Infant mortality rates also reflect broader social trends, including the prevalence of infants with low birth weight. The health system in the United States gives low birth-weight babies slightly better survival chances than does Canada’s, but the more pronounced difference is the frequency of these cases.

    In the United States, 7.5 percent of babies are born weighing less than 2,500 grams (about 5.5 pounds), compared with 5.7 percent in Canada. In both nations, these infants have more than 10 times the mortality rate of larger babies. Low birth weights are in turn correlated with teenage motherhood. (One theory is that a teenage mother is still growing and thus competing with the fetus for nutrients.)

    The rate of teenage motherhood, according to the O’Neill study, is almost three times higher in the United States than it is in Canada."

  7. To conclude, for the time being, let's look at this:

    "Finally, Canada counts births to Canadians living in the U.S., but not Americans living in Canada. In short, many nations count births that are in no way an indication of the efficacy of their own health care systems."

    Oh, by the way: I fully expect you to trot out your "conservative web site" excuse in an attempt to arbitrarily dismiss this

  8. There may be some merit to the premise that earlier treatment improves health outcomes for certain conditions, and this may theoretically explain part of Canada's superior infant mortality experience. But I think there is more to it than that.

    Yes, we are more affluent in the US. But that sometimes means that health behaviors can be worse. Obesity, sedentary behavior, smoking, substance abuse, and excessively early childbearing are all big issues in the US-- and I would like to venture a guess that these problems may be more prevalent than in Canada. And it has little to do with the respective health systems. It is partially economic, partially cultural.

    The genetic pool is a factor. Complicated pregnancies occur. Pregnancies with diabetes and hypertension are more risky. African-Americans probably have a higher prevalence of these conditions, and of certain negative health behaviors. This group accounts for a significant chunk of our infant mortality experience. We have more African Americans than Canada does.

    It should also be noted that pregnant women enjoy a high level of access to care in the US. Most places have a way for them to get care-- if not in the private sector, then through charity initiatives, or state and local health department programs. We also have WIC.

    And what Bubba is saying about the differences in measurement among countries makes sense also.

    Joe Guarino

  9. Bubba:

    Neat stuff. You're right that it is important to consider the denominator in an infant mortality calculation. I hadn't considered that other countries might use different definitions of stillbirths and spontaneous abortions.

    However, if you look through your article carefully, you'll see that Canada is never referenced. It turns out that Canada does not drop births the way that Germany and Austria do. Like the U.S., Canada counts very small birth weight babies and very early births. The latest report that I could find with their methodology and definitions was here.

    You have to discount the obvious liberal bias (they're Canadian after all). But their report (p. 89) says "Infant mortality has been considered the single most comprehensive measure of
    health in a society."

    With respect to Mankiw's op-ed piece, pre-term births, low-weight births, stillbirths, and miscarriages are all health outcomes. In essence, you and he are arguing that we should discount one good health outcome (lower infant mortality) because Canada also has lots of other good health outcomes.

    Canada does have a lower teen birth rate, but the teen birth rates in the U.S. and Canada have converged over time. Again, you can look at these as health outcomes. It turns out that rates of teenage sexual activity are roughly the same in both countries, yet for some reason pregnancy rates in Canada are about half those in the U.S. Could the reason be better access to contraception in the Canadian system?

    Not sure how the mixing argument affects the final numbers (and could find no evidence of this in the Canadian numbers). But wouldn't the presence of "healthy" Canadians in the U.S. push down the U.S. infant mortality rate?


    Just one thing to add. While most pregnant women in the U.S. eventually have access to suitable care, there are huge disparities in access to health care prior to pregnancy and early in pregnancy. You would know much better than I, but it seems that early access has a very big impact on eventual health outcomes. I doubt that those kinds of early-access disparities arise in the Canadian system.

    As I wrote earlier, Canada seems to do a very good job with the basics. The U.S. does a better job once you experience a really bad outcome. Doing better with the basics would substantially improve the U.S. system.

  10. I can't get the linked file to open properly, but from first look, it appears that the info on page 135 does not suport your premise.

    I'll try again when I have a little more time.

  11. "But wouldn't the presence of "healthy" Canadians in the U.S. push down the U.S. infant mortality rate?"

    You can't draw a conclusion about that without more information.

  12. Bubba:

    Page 135 is a list of end-note references. If you look through Appendix A (specifically, pp. 126-7), the methodology for determining fetal mortality rates indicates that low-birthweight and early births are counted among live births. Further on in the appendix, there is no indication that the infant mortality numbers exclude any live births.

    I also went back to the teen birth data. As your source indicates, the overall teen rate in the U.S. is three times higher than in Canada (about 42 per 1,000 U.S. teens versus about 14 per 1,000 Canadian teens). However, the rate among 10-14 year-olds is actually higher in Canada. Also, the vast majority of teen births (more than three-quarters are occuring to 18-19 year olds).

    Even so, in both countries, teen births are a small component of all births. Despite its higher teen birth rate, teen births in the U.S. only account for about 10 percent of all of the country's births (in Canada they are about 5 percent of all births). For teen births to account for the enormous difference in the countries' infant death rates, the rate among teenagers in the U.S. would have to be at least FOUR TIMES worse than among older women.

    Moreover, infant mortality rates among mothers age 20 and older are still substantially higher in the U.S. than Canada. Indeed, if you look at college-educated mothers age 20 and older in the U.S., their infant mortality rates are still slightly higher than the OVERALL infant mortality rate for Canada. Rates for less-educated U.S. women are substantially worse.

    BTW, I could find no direct references that indicated that Canada's own vital statistics exclude non-citizens. The relevant vital statistics are based on hospital discharges. So these data seem to be the same as the U.S.

    Your author appears to be referring to figures that were listed in an annual U.N. comparison report, not the figures reported by the CIA nor by Statistics Canada. Also, the U.N. figures that he cites are the HIGHEST mortality figures that I've been able to find for Canada, and they still indicate a roughly 25 percent difference with the U.S.

  13. Since the Canadian system is modeled after those which DON'T count live births/deaths, it is reasonable to expect Canada follows suit.

    In the overall measure of things, however, it is information found on my subsequent thread which provide all the information we need to determine that our American system is clearly superior to the Canadian one.