A recent post on the National Center for Policy Analysis's (NCPA) web site by Dr. Scott Atlas of the Hoover Institute and Stanford University expounded on 10 "surprising facts" about our health care system. After an opening statement that U. S. health care has been denigrated compared to other developed countries around the world, Atlas proceeds to present ten under-recognized "facts" that we should consider before turning to a larger role of government in health care.
This piece comes across as cherry picking of the literature to make the political point that we already have a good health care system, mostly because of the private sector and our advanced medical technology. It fits in well with the NCPA's announced goals "as a nonprofit, nonpartisan public policy research organization, established in 1983, with the goal to develop and promote private alternatives to government regulation and control, solving problems by relying on the strength of the competitive, entrepreneurial private sector."
The NCPA is one of the well-funded right-wing think tanks that uses its sizable corporate funding base to influence public opinion through hard-news coverage, television, talk shows, Op-Ed's and guest editorials in major newspapers, and Congressional connections. In a 2005 article in the International Journal of Health Services, "Myths and memes about single-payer health insurance in the United States: A rebuttal to conservative claims," I rebutted 20 of the NCPA's conservative claims as disinformation and myths.
So now Atlas brings forward 10 more "facts" that will surprise us -- except they are distorted and wrong. They again fit in well with the NCPA's agenda (1):
Alleged Fact 1: Americans have better survival rates than Europeans for
Alleged Fact 2: Americans have lower mortality rates than Canadians.
Alleged Fact 3: Americans have better access to treatment for chronic diseases
than patients in other developed countries.
Alleged Fact 4: Americans have better access to preventive cancer screening
Alleged Fact 5: Lower income Americans are in better health than comparable
Alleged Fact 6: Americans spend less time waiting for care than patients in
Canada and the U.K.
Alleged Fact 7: People in countries with more government control of health
care are highly dissatisfied and believe reform is needed.
Alleged Fact 8: Americans are more satisfied with the care they receive than
Alleged Fact 9: Americans have much better access to important new
technologies like medical imaging than patients in Canada or the U.K.
Alleged Fact 10: Americans are responsible for the vast majority of all health
Atlas concludes that "Despite serious challenges, such as escalating costs and the uninsured, the U.S. health care system compares favorably to those in other developed countries."
So let's examine some of these claims, which are supported by 16 carefully selected references to the literature, to see whether they hold any water. Rather than deal with all 10, this will look at four in enough detail to see the trends. We will soon see this presumably authoritative document is just another opportunistic use of data disguised as scholarship.
"Fact 1" claims that Americans have much higher survival rates for cancer of the breast, prostate and colon than their counterparts in Germany, the U.K and Norway.
"Fact 2" claims that Americans have lower mortality from breast and colon cancer than Canadians. However, as described in some detail in my most recent book The Cancer Generation: Baby Boomers Facing a Perfect Storm, these conclusions are based on five-year survival rates, a flawed method of evaluating outcomes. Although the five-year survival rates for Americans are higher for all cancers in this country compared with both men and women in Europe, researchers tell us that these figures are deceptive and incorrect because of several kinds of bias. For example, the study used by Atlas has no information on clinical stage of cancers. For valid cross-national comparisons, patients have to be matched for stage, since advanced-stage cancers will obviously have worse outcomes than early-stage cancers. There are other technical but crucial kinds of bias which have to be accounted for before drawing conclusions that we do better than other countries. The NCPA's "facts" did not consider other sources of bias, such as how much screening was done in each country, and are biased to a political conclusion that fits with its agenda.
"Fact 3" claims, on the basis of one reference and a reported difference in use of statins for cholesterol reduction, that Americans have better access to care of chronic diseases than do our counterparts in other developed countries. But that conclusion disregards solid evidence to the contrary as shown by a 2007 report by the Commonwealth Fund of a study of health system performance in seven countries -- Australia, Canada, Germany, the Netherlands, New Zealand, the U.K. and the U.S. That study asked a much broader question than the use of statins, asking respondents how often during the past year they did not see a doctor, did not get recommended care, or skipped doses/did not fill Rx because of cost? The results completely discredit "Fact 3"-- 42 percent of Americans answered "yes" to this question, three times the number of Canadians and almost five times the number people in the U.K. (2)
"Fact 7" alleges that Americans are more satisfied with our health care system than citizens in countries with more government involvement in health care. Atlas cites the above Commonwealth study to support a claim that "more than 70 percent of German, Canadian, Australian, New Zealand and British adults say their system needs 'fundamental change' or 'complete rebuilding.' That is true, but what Atlas doesn't tell us is that more Americans (82 percent) respond that way, more than respondents in any of the other countries. In fact, that study found that 34 percent of Americans believe that our system should be completely rebuilt, compared to only 12 and 15 percent in Canada and the U.K., respectively. (3)
As is well known, access, cost and quality of health care are interdependent and intertwined such that you can't evaluate one without the others. If many people cannot get past financial barriers to get access to needed care, they obviously have low quality of care. So it is cavalier and distortional for the NCPA paper to disregard our system's cost and access problems while claiming that our system compares favorably with other developed countries. Here are just a few objective cross-national comparisons among many that completely discredit any assertion of American superiority, or even equivalency in quality of health care compared with other developed countries:
- A 2008 report by the Commonwealth Fund found that the U.S. dropped from 15th in 2006 to last among 19 countries in 2008 on a measure of mortality that is amenable to medical care. (4)
- A 2007 report ranked the U.S. 42nd in the world for life expectancy, lower than most of Europe and Japan. (5)
- A 2006 study found that Americans in late middle age are less healthy than their counterparts in England for cancer and five other chronic diseases. (6)
- A 2007 study found that Canada has at least the quality of care as in the U.S., often with better outcomes, despite spending little more than one-half what we spend on health care. (7)
- An earlier study showed conclusively that poor women with cancer in Toronto have better outcomes than their counterparts in Detroit, even after accounting for race and standards of measuring poverty (for example, the Canadian women had survival rates more than 50 percent higher for lung, stomach and pancreatic cancer compared to American women in Detroit's poorest districts). (8)
- The U.S. has a weaker primary care system than other developed countries; it has been found to rank 11th among 11 countries on eleven performance criteria (9); our primary care base is in crisis with less than 10 percent of medical graduates now opting for careers as primary care physicians (10); moreover, patients living in parts of our country with larger number of specialists (and greater use of technology) are more likely to have late-stage colorectal cancer when first diagnosed. (11)
So much for the NCPA's latest surprising "facts", intended as they are to perpetuate the problems (and profits) of our unaccountable market-based system and protect private markets from health care reform. This kind of article by the NCPA does not advance the debate over how to fix our system, and instead is just another poorly disguised assault on the truth.
1. Schoen, C, Osborn, R, Doty, M M et al. Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. Health Affairs Web Exclusive 26, w 717-34, 2007.
2. Ibid # 5.
3. The Commonwealth Fund Commission on a High Performance Health System. Why not the best? Results from the National Scorecard on U.S. Health System Performance. Vol 97, July 17, 2008.
4. Associated Press. U.S. ranks just 42nd in life expectancy. Lack of insurance, obesity, social disparities to blame, experts say. August 11, 2007.
5. Banks, J, Marmot, M, Oldfield, Z et al. Disease and disadvantage in the United States and England. JAMA 295: 2037-45, 2006.
6. Guyatt, G H, Devereaux, P J, Lexchin, J et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine 1 (1), 2007.
7. Gorey, K M et al. An international comparison of cancer survival: Toronto, Ontario and Detroit, Michigan metropolitan areas. Am J Public Health 87: 1156-63, 1997.
8. Starfield, B. Primary Care: Concept, Evaluation and Policy. Oxford University Press. New York, 1992.
9. American College of Physicians. The impending collapse of primary care
medicine and its implications for the state of the nation's health care.
Washington, D.C. January 30, 2006.
10. Roetzheim, R G, Pal, N, Gonzalez, E C et al. The effects of physician supply
on the early detection of colorectal cancer. J Fam Pract 48 (11): 850-8, 1999.
Adapted from Do Not Resuscitate: Why The Health Insurance Industry Is Dying, and How We Must Replace It, and The Cancer Generation: Baby Boomers Facing a Perfect Storm, with permission from the publisher, Common Courage Press. Buy John Geyman's Books at Common Courage Press.
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