Last week's article on why 45 million Americans go without
health care insurance touched a nerve and generated many questions and
"You and your pesky statistics! Forty-five million Americans
without health care is huge. And you wrote that 89 percent of the 85 percent
of people with health insurance are satisfied. That means 25 percent of all
Americans are unsatisfied!"
Elder: Those "pesky" statistics become especially pesky when
misstated. I wrote that 45 million Americans have no health
insurance , leaving 85 percent with health insurance
but not without health care . ERs must
treat the uninsured, including illegal residents. Meanwhile, 89 percent of
Americans with or without insurance are satisfied with the quality of
their own health care .
An 89 percent satisfaction rate sounds pretty darn high. Are
people, for example, 89 percent satisfied with their jobs? Their marriages?
Their financial situations? Their experiences at concerts or ballgames or
restaurants or hotels or with airline travel? An 89 percent satisfaction
rate is pretty impressive for most things we pay for.
And as for the remaining 11 percent to what degree and for
what reason are they "dissatisfied"? Had bad experiences? Don't like having
copays? Would prefer a complete choice of doctors but are restricted by
their plans? Had to wait for appointments or sit too long in waiting rooms?
(Canadians are used to eight-month-or-more waits and long lines. Americans,
I assure you, are not.) A lot of people simply complain about most
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For example, 10 years ago I had laser eye surgery. I filled out
a questionnaire designed to determine how fastidious I am. Why? The doctor
told me the surgery would not get me 20/20 vision. Was I OK, the doctor
asked, with a less than 20/20 result? I was. He said some prospective
patients, however, are dissatisfied with such a result. Given their in
his view unrealistic expectations, the doctor wouldn't treat them.
"Doesn't universal coverage work in Canada?"
Elder: Not exactly. Large numbers of Canadians came (and still
come) to America to avoid waiting for MRIs or to get time-sensitive
treatment that couldn't wait. Canada is moving toward more privatization
which was previously illegal in Canada but is now permitted as a result of a
successful lawsuit. Imagine having to sue to spend your own money in a
voluntary transaction between two parties! According to a 2007 survey by the
Canadian Fraser Institute, the median wait time in Canada between visiting a
general practitioner and receiving treatment was more than 18 weeks and
up to 38 weeks for procedures such as orthopedic surgery.
"What's wrong with a government-provided alternative plan to
keep the insurance companies honest and more competitive?"
Elder: Here's a recent example of what happens when government
sets up "alternative" plans to cover the uninsured at (supposedly) lower
costs. Hawaii offered universal child health care for seven months. Then
it dropped the plan. Why? People (and employers) with private plans dumped
them to ride the "cheaper" government train. One of Hawaii's health care
administrators lamented, "I don't believe that was the intent of the
program." And Hawaii is a small state, without nearly the number of "health
insurance needy" as we have on the mainland.
"Come on! Obviously the American health care system IS broken!
That's why our life expectancy is so much lower and our infant mortality
rate is so much higher than in other countries."
Elder: Ezekiel Emanuel, a medical adviser to the President (and
brother of Rahm, the chief of staff), once told me, "Life expectancy is one
of the dumbest ways to measure the quality of a nation's health care."
Quality of medical care does not by itself determine life expectancy.
For example, deaths from accidents and murders are much higher in America
than in other developed countries. Texas A&M health economist Robert
Ohsfeldt and health economics consultant John Schneider calculated that if
accidental deaths and homicides during the '80s and '90s were removed from
the calculations, life expectancy in America would have ranked at the top of
all developed countries. What about personal behavior? Obesity leads to
serious health problems, including heart disease. One-third of Americans are
obese almost 50 percent more than the British and Australians, over 100
percent more than the Canadians and Germans, about 250 percent more than the
French and 1,000 percent more than the Japanese.
As for infant mortality, a 2007 study by economists June and
David O'Neill found that low birth weight drastically increases an infant's
chance of dying. They compared U.S. infant mortality (6.8 per 1,000 births)
with Canada's (5.3). Teen mothers are far more likely to have low-weight
babies, and America's teen motherhood rate is three times higher than
Canada's. They determined that if Canada had America's low-weight birth
distribution, Canada's infant mortality rate would rise from 5.3 to 7.06. If
America had Canada's low-weight birth distribution, our infant mortality
rate would fall from 6.8 to 5.4.
So don't blame the "broken health care system" for lower life
expectancies. American health care actually helps us cope with the
consequences of unhealthy lifestyles, keeping our ranking from being even