I have to disagree with macgyver Regarding the impact of immigration on healthcare in the US. I base this on a recent report by the Kaiser Family Foundation. http://www.kff.org/medicaid/upload/7761.pdf
Squid. Please don’t misinterpret my comments. They weren’t meant as an anti immigration statement just a statement of fact. I never said that immigration was the only or even a major factor, but it is a factor that must be considered when evaluating Americas success as a health care system. Immigrants may not make up the majority of the uninsured but they are a component of it. They tend to be lower income with less access to health care and therefor have higher rates of diseases like hypertension, diabetes, heart disease, smoking and other forms substance abuse. They also get treatment much later in the course of their illness and as a result have higher complication rates ( greater rates of premature births, low birth weights, diabetes induced kidney disease, heart disease, and stroke) Cancers are diagnosed at a later stage and therefor have lower cure rates.
Most efforts to grade or rate the health care systems of various countries do so by looking at things like infant mortality rates, heart disease rates, mammogram rates and so forth. The unique problems faced by immigrants will ultimately affect the ability of our health care system to meet their needs and thus affect the overall rating of our system to some extent. This is but one of many factors that must be taken into account when Americas system is compared to others.
I finally got a chance to view the entire PBS show “Sick around the world”. I found it pretty informative if somewhat incomplete. They do a reasonably good job of summarizing the plans in other counties although its hard to ignore T.R. Reids obscession with the fact that care is “free” in many of these countries ( He doesn’t say its free, but he practically drools over the idea that you don’t pay anything when you go to the doctor).
He conveniently fails to answer or glosses over a question that looms large for me as a physician. He consistantly reports how little doctors get paid in many of these countries ( although he only rarely gives figures, and even those are incomplete). He never says but clearly suggests that this is an important answer to the problem, but fails to explain how these couintries entice young students to give up nearly a decade of their lives and more than 8 years of earnings to go into medicine with no hope of ever recovering those losses. He briefly mentions a demonstration by doctors in Germany that went no where but then gives no further details. He mentions that doctors there make $80,000/ year but doesn’t put that in perspective or explain if this is a problem ( ie: Is Germany seeing fewer student going into medicine as time goes on? If not why not? Are there too few other opportunities in Germany for bright young students?). Where I live the base salary for a police officer is $100,000 and with overtime many make closer to $150,000. Who would go into medicine if they have no hope of making more than $80,000. There is clearly more to this story that he is not telling. Either he didn’t have enough time, is completely incompetant, or didn’t want to look at the downside of the systems he is clearly very enamoured with.
He also alludes to the fact that these countries only get low drug prices because america foots the bill for most of the research by paying higher prices. he doesn’t suggest how to fix that though if we negotiate the same low prices for our people ( I think we should, I just don’t know what the effect is going to be on innovation).
Aside from those shortcomings the program was actually quite intersting.
but fails to explain how these couintries entice young students to give up nearly a decade of their lives and more than 8 years of earnings to go into medicine with no hope of ever recovering those losses.
Well, I don’t know what entails to young people to study medicine here, but it happens. My wife is a physician (with especialisation in gynecology and obtetrics): she took seven year in college and after that four years in the especialization. The first seven was for free (college here is free), and in the last four she receive a small amount of money. She and her collegues are very poorly paid (for instance, she earns at year less than a quarter than my earning in the software industry). Despite their salaries, the med. college is full of people (and the engineering is almost empty, BTW)… why?. I don’t know.
Germany, France, and Canada all had immigration rates comparable to the US and yet do better than the US in WHO measures.
Most people who go into in to medicine often choose a highly skilled speciality because this pays better. However, there is over utilization of specialists. Most condations can be cared by a primary care provider (PCP). Medicare is in trouble because it promotes this being a procedure based payor. Yet the PCP who juggles the patients 6 medications, manages the patinet’s diabetes, hypertension, hyperlipidemia, etc is payed less than specialist who sees the patinet maybe three times.
Germany, France, and Canada all had immigration rates comparable to the US and yet do better than the US in WHO measures.
Most people who go into in to medicine often choose a highly skilled speciality because this pays better. However, there is over utilization of specialists. Most condations can be cared by a primary care provider (PCP). Medicare is in trouble because it promotes this being a procedure based payor. Yet the PCP who juggles the patients 6 medications, manages the patinet’s diabetes, hypertension, hyperlipidemia, etc is payed less than specialist who sees the patinet maybe three times.
Concerning immigration rates, it would be interesting to see that data as well as comparative data on the education level and economic status of the immigrants in those countries compared to ours. If you have any links I’d be interested in looking at that info.
As a PCP I agree with the second part of your statement 100%. Primary care docs are grossly undervalued in this country and specialists are overused and overpaid comparatively. All you have to do is ask a group of medical students about their plans for the future and you will quickly see that this point hasn’t been lost on them. They are all going into fields like radiology, invassive cardiology, and plastic surgery.
Sorry for the delay in response I have been away from my computer for the last 5 days. Unfortunately, i seem to have missed the discussion but I did want to respond to your post.
I would take issue with the value of the 2000 comparison done by the WHO. First, the criteria seems skewed against the US. Almost all of those nations get the free benefit of the billions in research done in the US which lowers their costs.
Further, one of the major criteria is life expectancy. This factor is worth double “system responsiveness.” There are multiple factors that make up life expectancy that have nothing to do with the healthcare system. Many of the illnesses that Americans suffer from come as a result of our bad diet and lack of exercise, not a lack of healthcare. In fact, the US is #1 in system responsiveness according to the WHO. In my opinion, those factors should be reversed as responsiveness of the system says a lot more about a health system.
Last, as I stated before, the US has a large diverse population which creates its own problems that most European nations do not face. Only seven countries that are ahead of the US on the WHO are even as big as Claifornia alone. How can one fairly compare us to San Marino, Andorra, and Malta? Even the larger countries on the list such as Japan, France and Germany do not have the unique issues we have as a nation. For those reasons, I would place very little value on the WHO comparison.
As an example, I would point out that the UK is ranked 18th in the WHO report, yet 6% of a 2007 study were having so much trouble getting dental care that they were doing their own work including pulling their own teeth. This alludes to the earlier point about rationing.
Germany, France, and Canada all had immigration rates comparable to the US and yet do better than the US in WHO measures.
Most people who go into in to medicine often choose a highly skilled speciality because this pays better. However, there is over utilization of specialists. Most condations can be cared by a primary care provider (PCP). Medicare is in trouble because it promotes this being a procedure based payor. Yet the PCP who juggles the patients 6 medications, manages the patinet’s diabetes, hypertension, hyperlipidemia, etc is payed less than specialist who sees the patinet maybe three times.
Concerning immigration rates, it would be interesting to see that data as well as comparative data on the education level and economic status of the immigrants in those countries compared to ours. If you have any links I’d be interested in looking at that info.
As a PCP I agree with the second part of your statement 100%. Primary care docs are grossly undervalued in this country and specialists are overused and overpaid comparatively. All you have to do is ask a group of medical students about their plans for the future and you will quickly see that this point hasn’t been lost on them. They are all going into fields like radiology, invassive cardiology, and plastic surgery.
I would be interested to know how immigration affects European healthcare as well. I wonder how that issue was accounted for in the report. Was immigration care ignored?
I’m not a doctor (obviously), but with regard to specialization, I’ve always thought that the advances in procedures and the proliferation and turnover of pharmaceuticals made specialists more and more necessary. I am engaged to a nephrologist and they are trying to get patients with kidney disease earlier in order to begin observing and potentially treating patients early to avoid dialysis as long as possible. Anecdotal evidence is always a dangerous argument, but I am posing more of a question than disagreeing.
I think if you take all of the data I presented together it will give you a more accurate picture of the US healthcare situation. Europe as a whole is very diverse, and yet they are able to get healthcare outcomes markedly better than ours for less money per capita.
In addition, the news report you cite needs to be looked at carefully. The claim that “some” people self-treat is true in the US as well; pulling one’s own teeth sounds horrid, and makes a good headline, but what are the numbers and how do they compare?
The data they provide is:
More than three-quarters of those who have a private dentist consider they were forced into it because their own dentist went private or they could not find an NHS dentist.
Just over 10% were not registered with a dentist at all. A third of those (35%) said there were no NHS dentists nearby, 22% said they did not know how to find one, 13% said they were on a waiting list and 30% said there were other reasons.
But 6% of the respondents said they were self-treating ...
So the problem here is that 10% could not find a (free) NHS dentist nearby and so had to take other measures.
Let’s compare this with the US. See, for example, HERE:
Seventy-seven percent of U.S. children had dental insurance; of these, 29 percent had public dental insurance. Overall, 16.3 million children lacked dental insurance, 2.6 times the number of children who did not have medical insurance. Children uninsured for dental care were less than half as likely to have received PDC [Preventive Dental Care]. Among children without dental insurance, 3 million were potentially eligible for public dental insurance and 8 million had private medical insurance but no dental insurance. While the majority of children younger than 3 years had dental insurance, few received PDC (for example, 76 percent of 2-year-olds had dental insurance but less than one-quarter had received PDC).
So in the US, 23% of children lacked dental insurance as of this report in 2007.
… there are over 150 million Americans with limited or no dental insurance, according to the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services (HHS). ... Lack of dental insurance affects dental utilization and oral health status. For example, 48.2 percent of people without private dental insurance did not have a dental visit in the last year, compared to 28 percent with insurance, according to data from Dental Services and Oral Health: United States, 1989.
I doubt that things have gotten any better in the intervening nine years.
I would be interested to know how immigration affects European healthcare as well. I wonder how that issue was accounted for in the report. Was immigration care ignored?
I’m not a doctor (obviously), but with regard to specialization, I’ve always thought that the advances in procedures and the proliferation and turnover of pharmaceuticals made specialists more and more necessary. I am engaged to a nephrologist and they are trying to get patients with kidney disease earlier in order to begin observing and potentially treating patients early to avoid dialysis as long as possible. Anecdotal evidence is always a dangerous argument, but I am posing more of a question than disagreeing.
Immigration and its effect on the delivery of health care was not addressed in the report since its a relatively minor issue. If you check my post above it gives a link to the show so you can watch it online. You and your fiance would probably find it very interesting. Here’s the link
Advances in medicine do result in greater specialization, but they do not diminish the need for good primary care. As physicians become more specialized they know less about subjects outside their small field of interest. If anything, the onward march of progress makes a good primary care physician more relevant and critical than before. I would estimate from my own experience that 90% of the day to day problems peopls have can be handled by a primary care doctor. Primary care doctors are the ones who make most of the diagnosies. A patient never presents to his/her physician with Lymes disease. Instead they come to the doctor with a constellation of symptoms - joint pains, headache, maybe a rash, maybe palpitations or neurologic symptoms. Without a primary care doctor to put the pieces together and make the right diagnosis the patient would be left wandering from specialist to specialist trying to figure out what is wrong. Should she go to a cardiologist, a neurologist, a dermatologist? The example you site about your fiance being a nephrologist and trying to get patients with kidney disease treated sooner. Who do you think will get them to the nephrologist sooner? Not the nephrologist. Its the Internist or GP who needs to identify the problem early in order to get the person to a nephrologist. More importantly, its the Internist and GP who will be the ones to prevent,diagnose, and treat the hypertension and diabetes that lead to most cases of renal disease.
Specialists will always be needed, but the problematic trend we are seeing is that greed rather than need is driving the rate at which young physicians choose their specialty. Our current reimbursement system makes it more profitable to go into a specialty than to do primary care medicine. The free market system no longer works in the medical field. Since we physicians can always create more demand , the supply/demand mechanism that would normally steer physicians away from an oversupplied medical specialty toward an undersupplied one like primary care has been short circuited. Part of the problem is the general tendency of society and hence insurance compaies to value invassive and surgical services above cognitive ones. There is a saying in medicine “You get paid to do, not to think”. The Cardiologist who does your cardiac catheterization may get paid $5000 for an hours work, but the Internist who first saw you for the problem, made the diagnosis, talked to you about lifestyle changes, designed a drug regimen to control your hypertension, cholesterol, and diabetes, and then discussed the case with the cardiologist and arranged the consultation may recieve $200 for a combined 2-3 hours of work. Unless thes things change there will be mmore and more specialist and fewer Primary care docs. Not because that is what we need, but because that is what we value.
Germany, France, and Canada all had immigration rates comparable to the US and yet do better than the US in WHO measures.
Most people who go into in to medicine often choose a highly skilled speciality because this pays better. However, there is over utilization of specialists. Most condations can be cared by a primary care provider (PCP). Medicare is in trouble because it promotes this being a procedure based payor. Yet the PCP who juggles the patients 6 medications, manages the patinet’s diabetes, hypertension, hyperlipidemia, etc is payed less than specialist who sees the patinet maybe three times.
Concerning immigration rates, it would be interesting to see that data as well as comparative data on the education level and economic status of the immigrants in those countries compared to ours. If you have any links I’d be interested in looking at that info.
As a PCP I agree with the second part of your statement 100%. Primary care docs are grossly undervalued in this country and specialists are overused and overpaid comparatively. All you have to do is ask a group of medical students about their plans for the future and you will quickly see that this point hasn’t been lost on them. They are all going into fields like radiology, invassive cardiology, and plastic surgery.
Thanks Squid. That information is somewhat helpful but unfortunately doesn’t answer the questions I had ie: How do european immigrants compare to U.S. immigrants in terms of socioeconomic factors like education and wealth? These are the two of the most important factors that affect an individuals access to health care and compliance with public health initiatives. It would also be interesting to know what percent of immigrants in each society speak the native language since this also can be a barrier to entering the health care system of course, but its also a barrier to communication with the health care provider that could ultimately lead to less effective care. I’ve done a google search but I can’t seem to find a source that makes these comparisons. I think we would have to collect the raw data ourselves and then analyze it. I don’t have the time for that unfortunately.
My position has been that immigration was one of many factors that may explain part of the poor ranking the U.S. health care system recieved. Without evidence to support or refute my contention, I will amend my statement and say its a ‘possible’ factor. Obviously there are many problems with the system itself that play a much bigger role such as the cost and lack of universal coverage.
I maintain my original position. All Americans are morally entitled to health care and health insurance. When debating parties begin parsing details like immigration rates, specialists vs. PCP’s, low salaries for MD’s etc, they are really just defending the indefensible status quo. Seeing the health care systems in Europe clearly is difficult if not impossible for many Americans who are used to thinking of money first and as the most important component of anything. So if European medical schools are full of potentially underpaid doctors, that says more about the writer of that statement than about the needs of those same doctors. Obviously the doctors either don’t need as much money as American doctors do or they must feel valuable in other intangible ways that are more meaningful. The truth is that higher taxes pay for medical care there, and it is “free” at time of visit in most of Europe. In America, we have some strange notion that taxes are basically unjust and we forget that taxes are the government’s way of ensuring the safety, health, education and welfare of its citizens. Comparing the 2 systems without being thoroughly versed in the completely different systems is useless, and the comparisons will suffer as a result because of unconscious pro-America prejudice.
The president of my company said something interesting yesterday. That 19% of patients in hospitals are in the hospital due to something that happened after they went to the hospital. I’ll have to pin him down on a source, but he normally remembers things he reads very well.
I apologize for the length of time between responses. I recognize that it is tedious for you, but work has kept me too busy to respond properly. For controversial issues, I don’t like to speak on this forum without being able to back up a point so it’s better to say nothing than say something wrong. I acknowledge that I spoke off the cuff with my initial response regarding the VHA. I’ve had a fair amount of interaction with clients and the VHA and have come away underwhelmed with the care and treatment especially as someone’s condition becomes more complicated. Personal anecdotal evidence is not as powerful as national stats though and I concede that the VHA has improved significantly in the last 12 years. I would still contend that VHA care is not equal to private care though.
Interestingly, in researching this issue, I learned something else that benefits my argument. Paul Krugman said that the VHA has cut bureaucracy and I knew that was wrong. In checking, I learned that contrary to what I and probably many others believed, the VHA does not provide unqualified care to all veterans. Vets are classified into priority categories based on their length of service, record, and rank and then certain treatments are made available to them based on their priority classification and the money available each year by budget. Thus, the VA really does not provide free medical care to all vets the way most people think it does. Further, benefits for the same person can fluctuate from year to year based on the budget and changes in priorities.
Mr. Krugman’s article is misleading in that while the VHA contains cost by being efficient, but more significantly, it also picks and chooses the number of patients it will see, the treatments that will be provided, and limits treatment availability based on its budget. If you think about it, the VHA approach makes a better argument against mandates and fully socializing medicine since even under the best of conditions, being run efficiently and well funded, the system still does not provide full healthcare to all.
We can go back and forth with statistics all day. For example, I think your numbers on uninsured children are off. I found a site that indicates 9 million children don’t have dental care. That’s a lot but it falls more in line with the 1 in 7 uninsured number. These numbers are deceiving. For example, the 47 million uninsured is the number of people who went without insurance for part of 2007. It doesn’t mean they were uninsured all year. This number also does not take into account the number of people who can afford to have healthcare but choose not to pay for it.
You make good points, I always find your posts among the best on the site. The problem for me and the probable difference between our point of views are that I don’t trust our government with such a large program as socialized healthcare. Look at the mess they have made of social security. More fundamentally, I would probably also disagree with you and many others on this site insofar as I do not believe one has a legal or Constitutional right to healthcare, but that is a whole different discussion.
Sorry for the length of the post, I am too verbose.
Interesting front-page article in today’s NYTimes about health insurance. It’s worth a look. Click HERE to read the whole thing. (May require login).
Even the Insured Feel the Strain of Health Costs
By REED ABELSON and MILT FREUDENHEIM
Published: May 4, 2008
The economic slowdown has swelled the ranks of people without health insurance. But now it is also threatening millions of people who have insurance but find that the coverage is too limited or that they cannot afford their own share of medical costs.
<snip>
The problem of affording health care is most acute for people with no insurance, a group expected to soon exceed 48 million, but those with insurance say they too are feeling the pain.
Since the recession of 2001, the employee’s average cost of an annual health care premium for family coverage has nearly doubled — to $3,300, up from $1,800 — while incomes have come nowhere close to keeping up. Factor in other out-of-pocket medical costs, and the portion of the average American household’s income that goes toward health care has risen about 12 percent, according to the consulting and accounting firm Deloitte, and is now approaching one-fifth of the average household’s spending. ...
