Demand Supply

By many tangible measures, the U.S. health care system isn’t much to brag about. For example, the World Health Organization reported that in 2000 the U.S. ranked 24th in the world in “healthy life expectancy.”

“Basically, you die earlier and spend more time disabled if you’re an American rather than a member of most other advanced countries,” said Christopher Murray (M.D., Ph.D.), Director of WHO’s Global Programme on Evidence for Health Policy.

In life expectancy, infant mortality, and number of practicing physicians per capita, the U.S. long has ranked near the bottom among the 30 or so wealthiest industrialized nations. And this is in spite of the fact that we spend nearly twice as much per capita on health care as nations that get much better results than we do. We don’t even have as many hospital beds per capita as most other industrialized nations.

But worry no more, children. I learned today that “US Health Care Saves More Lives Than Socialized Medicine.” Captain Ed writes,

A new study by the Karolinska Institute in Sweden shows that the American health care system outperforms the socialized systems in Europe in getting new medicines to cancer patients.

According to the document linked by Captain Ed, “The proportion of colorectal cancer patients with access to the drug Avastin was 10 times higher in the US than it was in Europe, with the UK having a lower uptake than the European average.” In other words,if you are a colorectal cancer patient lucky enough to have health insurance and get diagnostic tests in time, you are far better off in the U.S. than anywhere else.

What more do you need to know? That proves the U.S. has The Best Health Care in the Worldâ„¢, right?

I understand the U.S. is still ahead of most other countries in the development of new drugs and high tech gizmos for diagnosing and treating diseases. Unfortunately, hospital care is not the be-all and end-all of health care. Take our famously nasty infant mortality stats, for example. On the whole I don’t believe we’re losing babies because of substandard hospital care. On the contrary; I’ve heard many times that the United States has superior intensive hospital care for high-risk neonates compared to other nations. However, as this abstract says,

Despite high per capita health care expenditure, the United States has crude infant survival rates that are lower than similarly developed nations. Although differences in vital recording and socioeconomic risk have been studied, a systematic, cross-national comparison of perinatal health care systems is lacking. …

… Compared with the other 3 countries, the United States has more neonatal intensive care resources yet provides proportionately less support for preconception and prenatal care. Unlike the United States, the other countries provided free family planning services and prenatal and perinatal physician care, and the United Kingdom and Australia paid for all contraception. The United States has high neonatal intensive care capacity, with 6.1 neonatologists per 10 000 live births; Australia, 3.7; Canada, 3.3; and the United Kingdom, 2.7. For intensive care beds, the United States has 3.3 per 10 000 live births; Australia and Canada, 2.6; and the United Kingdom, 0.67. Greater neonatal intensive care resources were not consistently associated with lower birth weight-specific mortality. The relative risk (United States as reference) of neonatal mortality for infants <1000 g was 0.84 for Australia, 1.12 for Canada, and 0.99 for the United Kingdom; for 1000 to 2499 g infants, the relative risk was 0.97 for Australia, 1.26 for Canada, and 0.95 for the United Kingdom. As reported elsewhere, low birth weight rates were notably higher in the United States, partially explaining the high crude mortality rates.

Conclusions. The United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality. Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of US reproductive care resources and its emphasis on neonatal intensive care.

(The study discussed in the abstract was published in the Journal of the American Academy of Pediatrics [PEDIATRICS Vol. 109 No. 6 June 2002, pp. 1036-1043] and is by Lindsay A. Thompson, MD, MS, David C. Goodman, MD, MS, and George A. Little, MD.)

Basically, our health care system is good at delivering difficult and expensive stuff but blows at simple, ordinary stuff, like preventive care, compared to other nations. This means we save some lives that might have been lost in Europe, but we also lose lives that would have been saved in Europe.

How did this come to pass? Certainly we Americans value creation and innovation. But it’s also the fact that our private, profit-based health care system is very good at creating new health care products that will make a lot of money. But where there’s no chance of profit, forget it.

This is what the “magic of the marketplace” has given us. You know how markets work; where there’s a demand, someone will hustle to provide a supply, and competition encourages the creation of better products at lower cost. Our system is very good at creating new drugs and new technologies and then marketing them to hospitals, physicians, and even potential patients. And I’m not saying this is a scam; many of us have benefited from the drugs and gizmos. The problem is that some parts of the health care process just don’t make any money. And where it isn’t profitable, our system is falling apart.

Yesterday I wrote about our nation’s emergency rooms. In short, they’re bad, and they’re getting worse. Emergency room capacity is shrinking, although demand is growing. People are dying because they wait too long to get treated.

Go to to read the second part of their three-part series on the crisis in emergency medical services. Then ask yourself if this is the sort of emergency care you’d like for yourself or someone you care about. Probably, it isn’t.

But emergency rooms are big money losers for hospitals. They suck up expensive resources, and often the people who use ERs have no insurance and can’t pay.

Here’s what the “free market” people never seem to wrap their heads around: Unprofitable demands do not generate supply, even when those demands are desperately needed.

Put another way, not everything that’s worth having can generate enough profit to pay for itself.

Most nations come up with a simple answer to this problem: They pay for vital but unprofitable services with taxes. That’s a big part of what government is for, some would argue. But you know American conservatives; they’d rather accept greater suffering and death (as long as it isn’t theirs) than pay taxes that support a dreaded “entitlement” like basic health care. It just sticks in their craw that their tax dollars might be used to benefit someone else. And it never occurs to them that someday they might be the “someone else.”

Of course, the irony of this is that, thanks to lobbying and other efforts, some parts of the health care industry enjoy generous corporate welfare. But to Republicans welfare is just fine as long as it’s going to them.

By now “market forces” have so skewed our health care delivery system that, even if we began to allocate our health care dollars according to need rather than profit, it would take years before the neglected parts of our systems were built back up to where they should be.

While our emergency rooms rot, the health care industry just loves to provide boutique medical services for health care consumers who can pay for them. Expensive mass market ad campaigns are aimed at people with unsightly toenails, male pattern baldness, and erectile dysfunction to drive up optimum demand for the product before the patent runs out. For example, recently I’ve seen ads in which young women are sitting around a table discussing a newly discovered premenstrual syndrome — it sounds just like PMS to me, but apparently it’s much worse — for which there is (surprise!) a remarkable new drug to treat it.

If you’ve got toenail rot and insurance, Big Pharma wants your business. If you bust your head open and need your life saved in an ER — good luck.

I’m not a bit surprised that the U.S. is doing a good job of developing and delivering new cancer drugs to patients, because that’s the sort of thing we’re still doing well. But to extrapolate from this news that the entire U.S. health care system is superior to the “socialized” systems of Europe is, um, a bit of a stretch.

Getting Even

Margaret Talev and Marisa Taylor of McClatchy Newspapers report that

Only weeks before last year’s pivotal midterm elections, the White House urged the Justice Department to pursue voter-fraud allegations against Democrats in three battleground states, a high-ranking Justice official has told congressional investigators.

In two instances in October 2006, President Bush’s political adviser, Karl Rove, or his deputies passed the allegations on to Attorney General Alberto Gonzales’ then-chief of staff, Kyle Sampson.

Sampson tapped Gonzales aide Matthew Friedrich, who’d just left his post as chief of staff of the criminal division. In the first case, Friedrich agreed to find out whether Justice officials knew of “rampant” voter fraud or “lax” enforcement in parts of New Mexico, Pennsylvania and Wisconsin, and report back.

But Friedrich declined to pursue a related matter from Wisconsin, he told congressional investigators, because an inquiry so close to an election could inappropriately sway voting results. Friedrich decided not to pass the matter on to the criminal division for investigation, even though Sampson gave him a 30-page report prepared by Republican activists that made claims of voting fraud.

Friedrich testified in a closed-door session, but a “senior congressional aide familiar with the testimony” described it to McClatchy Newspapers.

After Murray Waas reported yesterday

The Bush administration has withheld a series of e-mails from Congress showing that senior White House and Justice Department officials worked together to conceal the role of Karl Rove in installing Timothy Griffin, a protégé of Rove’s, as U.S. attorney for the Eastern District of Arkansas.

… I’d say it would be hard for the White House to claim that Karl or somebody was not trying to use the Justice Department to gain advantage in midterm elections. The White House, of course, claims this anyway.

At Salon, Garrett Epps writes that “the assault on voter fraud was a solution looking for a problem.”

Republicans do cherish their little practical jokes — the leaflets in African-American neighborhoods warning that voters must pay outstanding traffic tickets before voting; the calls in Virginia in 2006 from the mythical “Virginia Election Commission” warning voters they would be arrested if they showed up at the polls. The best way to steal an election is the old-fashioned way: control who shows up. It’s widely known that Republicans do better when the turnout is lighter, whiter, older and richer; minorities, young people and the poor are easy game for hoaxes and intimidation.

The latest and most elaborate of these jokes is the urban legend that American elections are rife with voter fraud, particularly in the kinds of poor and minority neighborhoods inhabited by Democrats. In 2002, Attorney General John Ashcroft announced that fraudulent voting would be a major target of the Department of Justice. As the New York Times reported last month, the main result of this massive effort was such coups as the deportation of a legal immigrant who mistakenly filled out a voter-registration card while waiting in line at the department of motor vehicles.

But the administration has remained ferociously committed to suppressing voter fraud — as soon as it can find some.

I like this bit:

As part of the Help America Vote Act, Republicans insisted on creating the Election Assistance Commission, which commissioned studies of the asserted problem. When the studies failed to turn up evidence of fraud nationwide, appointed Republican officials on the EAC insisted that the language say only that “there is a great deal of debate on the pervasiveness of fraud in elections” — the same approach to inconvenient evidence that’s made the Bush global-warming policy the envy of the world.

IMO the legend that Democrats only get elected because they cheat has been brewing among Republicans for decades. You might remember that the old big city bosses, from William Tweed of New York to Richard Daley (the Elder) of Chicago, were famous for delivering votes for Democrats using less than honest means. But though he’s been dead for more than thirty years, the ghost of Richard Daley, the last of the bosses, still haunts the GOP.

For decades after the 1960 presidential elections Republicans complained that John Kennedy beat Richard Nixon only because Daley stuffed ballot boxes to deliver Chicago (and thereby Illinois) for Kennedy, and Lyndon Johnson likewise fixed the vote in Texas. The legend is that Richard Nixon shrugged it off and let Kennedy get away with stealing the election. The truth is that local and national GOP officials investigated allegations of fraud vigorously and challenged results in many precincts in court. As David Greenburg wrote in Slate awhile back, the only tangible result of the several recounts was that Hawaii’s three electoral votes were taken away from Nixon and given to Kennedy. Otherwise, whatever fraud probably occurred wasn’t significant enough to have changed the outcome.

Nevertheless, I noticed through the years that many rank-and-file Republicans nursed a massive grudge about being cheated at the polls. As a result, IMO, they see fraud every time a Democrat wins an election. And they’ve developed a sense of entitlement that it’s OK for them to cheat back.

An article by Phyllis Schlafly written in December 2000 justifies George Bush’s “win” by dredging up the ghost of the 1960 election (“The stuffing of the ballot boxes in Cook County, Illinois and in Texas has been so well substantiated that it is no longer disputed today.”) and implying that William Daley, Gore’s campaign manager, was a vote-stealer like this old man.

See also this “analysis” of the 2000 Florida recount that presents most of the rumors and allegations flying around at the time —

As this is written, we do not know who will be the next president,” the editorial page of the Wall Street Journal declared on Nov. 9, 1960, as the nation awaited results in the presidential contest between Sen. John F. Kennedy of Massachusetts and Vice President Richard M. Nixon. The closeness of that 1960 race and the undeniable fraud were followed by the manly response of Nixon. What a far cry that was from the lachrymose Chinese opera now surrounding Al Gore and George W. Bush as history no longer is being repeated but reshaped.

Despite allegations of Democratic election fraud, particularly in Texas and Chicago, where former senator Lyndon Johnson and the family of former mayor Richard J. Daley were past masters at political pilfering, the Nixon campaign surmised that legal challenges would, in the end, be fruitless. The Gore campaign saw the landscape differently. In fact, it produced a “Chad”-aquiddick drama that has cast a cloud over the Sunshine State’s 25 electoral votes — something which may have been foreseen by Gore when he chose Richard J. Daley’s son, William Daley, to be his campaign manager.

The pattern was there. From the hyperactive get-out-the-vote effort launched by the Democratic National Committee and such sympathetic interest groups as the National Association for the Advancement of Colored People and organized labor, the ward-healing Democrats were well ahead of their more inhibited GOP rivals. With Gore unable to gin up enough energy with his policy lectures and high-spirited, pulpit-pounding pronouncements, the party stepped up its effort to scour every county, district and precinct in search of Gore voters who might be bused, wheeled or carried drooling to the polls. Churches, schools, homeless shelters, mental asylums, nursing homes and even prisons were seen as housing potential voters to do their bit for the veep.

I remember at the time encountering a Bush supporter who was absolutely certain the Gore campaigned had bussed thousands of illegal immigrants across the border to vote for Gore. There were also rumors about thousands of convicted felons who had voted for Gore.

I have no idea if Karl Rove himself believes the legends, but I do know that Karl is brilliant at manipulating right-wing resentment and paranoia about “liberals” and Democrats. That’s where the sense of entitlement comes in; the Right long has believed it is literally at war with us, and all’s fair in war. Take, for example, the so-called “Brooks Brothers riot” of paid GOP operatives who terrorized the Miami-Dade canvassing board into stopping their vote recount. To us, that was bare-knuckle thuggery. But to righties it was a righteous strike for justice against an evil, powerful oppressor.

At this point I don’t think any amount of hard evidence would dissuade these loons that voter fraud is not the massive problem they think it is and that they are not entitled to cheat back. They see themselves as the peasants storming the Bastille. And yes, they’re nuts. What else is new?