Krugman: Ignorant, or a Liar?

August 12th, 2008 | by Brian Schwartz |

Paul KrugmanWhat’s easy about guaranteed health care for all? For one thing, we know that it’s economically feasible: every wealthy country except the United States already has some form of guaranteed health care. - Paul Krugman, August 10, 2008

Many pundits see red at the words “single-payer system.” They think it means low-quality socialized medicine; they start telling horror stories — almost all of them false — about the problems of other countries’ health care. — Paul Krugman, May 1, 2006

If citizens of these other wealthy countries have guaranteed care, can Dr. Krugman explain to me to following instances of people in these countries not getting needed medical care?

  • The British National Post reports on “How the NHS is letting my father die - by a top hospital consultant.”
  • The Globe and Mail reports that “More than 100 Canadian women with high-risk pregnancies have been sent to United States hospitals over the past year – in what a doctors’ group attributes to the lack of a national birthing plan.”
  • The Canadian Medical Association Journal reports that in one year, 71 Ontario patients died while waiting for coronary bypass surgery and over one hundred more became “medically unfit for surgery.”
  • The Canadian Broadcasting Corporation reports that “109 people had a heart attack or suffered heart failure while on the waiting list. Fifty of those patients died.”
  • The Globe and Mail reportedthat “Inside Sylvia de Vries lurked an enormous tumour and fluid totalling 18 kilograms. But not even that massive weight gain and a diagnosis of ovarian cancer could assure her timely treatment in Canada.”
  • The Globe and Mail also reported that “More than 400 Canadians in the full throes of a heart attack or other cardiac emergency have been sent to the United States because no hospital can provide the lifesaving care they require here.”
  • The BBC reports that “up to 500 heart patients die each year while they wait for potentially life-saving surgery.” The Times reports that a British woman “will be denied free National Health Service treatment for breast cancer if she seeks to improve her chances by paying privately for an additional drug.”
  • A Daily Telegraph headline reads: “Sufferers pull out teeth due to lack of dentists.” “Doctors are calling for NHS treatment to be withheld from patients who are too old or who lead unhealthy lives,” reports another article.
  • [update, Aug 14] An August 13 Telegraph headline reads: “Patients ’should not expect NHS to save their life if it costs too much’ The NHS should not always attempt to save someone’s life if the cost is too much, the medical regulator has ruled.”
  • [update, Sept 2]: The Independent (UK) reports that “A cancer charity has today published research that shows doctors are keeping cancer patients in the dark about new treatments that could extend their lives.” (via FIRM)
  • [update, Sept 2]: And for those who hate anecdotes of those who do not receive care where government supposedly “guarantees it,” BigGovHealth.org keeps a growing list.
  • [update, August 18]: “Kidney cancer patients denied life-saving drugs by NHS rationing body NICE,” Daily Mail 4-29-09
  • See my other posts on government health care rationing, including this video about rationing in Oregon.

Are any of the above false?  And if the governments of these countries ”guarantee” health care to citizens, how could the above situations occur?

Unlike Paul Krugman, I do not have a Ph.D. in Economics, have a column in the New York Times, and Princeton University does not employ me as a professor.  So maybe I lack some insight that he possesses.

Or could he be trying to deceive readers?  Or is he just ignorant?  Other explanations?

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  • BRIAN K
    My hat is off to you. As a physician whose specialty training took place in Seattle, we regularly saw patients transferred down to the US after sitting in an ICU for 10 days on maximal Heparin and Nitroglycerin therapy with unremitting chest pain. We would get them, do quick angiogram and type them for blood and then STAT off to the OR for definitive therapy. The care they had received in Canada would have been actionable Malpractice here. I have no idea how many died while waiting for transfer.
    The thought of imposing this bureaucratic system in the US makes me ( and pretty much every physician I know) shudder at the thought.
    Good luck to all you non-medical people without an inside connection. You'll find yourself waiting for therapies no one even tells you exist..
  • ajparrillo
    You last reply addressing developmental measures is a list of conjecture with no evidence of the explanations. Further, if others are commending you for putting shadowfax in his place, then I am discouraged at what passes for empirical debate. Finally, your arguments clearly come from an ideological underpinning and therefore make limited, anecdotal arguments that conform to your viewpoint...as do many of the commentators you mention. Let's look at our problems from a pragmatic point of view and stop being politically lazy and take responsibility for the government...then it won't be out to get us.


    Brian replies:
    I am once again baffled as to what would qualify as empirical debate if the studies I mention do not. I further emphasize the studies in response to an earlier comment.

    Is there something wrong with having political beliefs based on an "ideological underpinning"? And by what standard or ideal would this be wrong? To take an example most of us would agree with, consider slavery before the Civil War. Should people debate its merits or lack of merit on a "pragmatic" level?

    To me, it's lazy to hand one's money over to the government and expect them to be accountable in running social programs. It disempowers you. Why not take personal responsibility for what you value by donating to charities that you think are doing a good job? If you don't like what the charity has done, then you take responsibility by donating to another one. That's how we act with restaurants and grocery stores. We vote with our feet, and the institutions respond accordingly.
  • paddingtongreen
    First the disclosure; I have dual nationality and have long experience with BCBS and the NHS.

    Brian, you do your case a disservice by quoting diverse incidents and reports rather than real statistical studies. Some of the "reports" are suspect - the Telegraph is a conservative newspaper with a hatred of the Labour Party and will publish anything detrimental that has the slightest substance.

    The NHS is governed regionally, so a ruling in one region does not necessarily govern in the others, and should not be thought of as doing so; our health services is controlled by different insurance companies with different sets of rules but no one here assumes that a denial of service by one, applies to all.

    My challenge to you - can you say that each of the incidents/reports could not be equaled by a similar report/incident, here in the USA, even on a per capita basis.

    Further, do you deny that, even with the listed shortcomings, the expectation of life, and the infant mortality rates of those countries are considerably better than here? and at lower per capita cost?


    Brian replies:
    Studies vs. adecdotes:
    I do list studies. The BBC reported “up to 500 heart patients die each year while they wait for potentially life-saving surgery.” That was from a study. When the Canadian Broadcasting Corporation reports that “109 people had a heart attack or suffered heart failure while on the waiting list. Fifty of those patients died,” that was also from the study. The Canadian Medical Association Journal reports that in one year, 71 Ontario patients died while waiting for coronary bypass surgery and over one hundred more became “medically unfit for surgery.” That's a study, too. This is quite apparent if you follow the links.

    If you're concerned about surviving cancer, check out a study from The Lancet.

    And as I said before, the point of the post is to refute Krugman's claim that "every wealthy country except the United States already has some form of guaranteed health care." You don't need studies for that, just examples. The point of this post is not to show that health care in the U.S. (which government interferes with significantly) is better. You might even say the the U.S. already has socialized medicine.
    Life expectency: I've quote John Stossel on this before:

    life expectancy [is] lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That’s not a health-care problem. …

    When you adjust for these “fatal injury” rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.

    Diet and lack of exercise also bring down average life expectancy.


    Also see this article and this blog post.

    Infant Mortality:
    Check out what David Hogberg writes:
    Inconsistent measurement explains only part of the difference between the U.S. and the rest of the world. Were measurements to be standardized, according to Eberstadt, "America might move from the bottom third toward the middle, but it would be unlikely to advance into the top half."22 Another factor affecting infant mortality Eberstadt identifies is parental behavior.23 Pregnant women in other countries are more likely to either be married or living with a partner. Pregnant women in such households are more likely to receive prenatal care than pregnant women living on their own. In the U.S., pregnant women are far more likely to be living alone. Although the nature of the relationship is still unclear (it is possible that mothers living on their own are less likely to want to be pregnant), it likely leads to a higher rate of infant mortality in the U.S.


    In summary, infant mortality is measured far too inconsistently to make cross-national comparisons useful. Thus, just like life expectancy, infant mortality is not a reliable measure of the relative merits of health care systems.


    And consider this from U.S. News and World Report:
    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.


    See also here:
    It turns out that once we condition on infant birthweight–a significant predictor of infant health–the U.S. has equivalent infant mortality rates. In fact U.S. infant mortality is lower for low-birthweight babies than Canadian infant mortality for low birthweight babies. Overall infant mortality, however, is higher in the U.S. because the incidence of babies with low birthweight is higher than in Canada. This may be due to demographic or epidemiological factors, or it may be the case that the U.S. is better at having a live birth for a low birthweight baby.
    I'd need to look at that further to better understand their claim.

  • Sylvia
    I live in Brooklyn, NY and I see frequent news stories in the neighborhood papers and sometimes in the Daily News, Newsday and The Post about local families whose precious child is dying of cancer. Friends and relatives will be holding a fund raiser for the child's continued treatment. Donations will be accepted. Make checks out to Such & Such Fund, 1 Smith St, Bklyn, NY 11201. If our health care system is so wonderful why do so many have to resort to charity?


    Brian replies:
    Sylvia, I am sorry to hear about the child with cancer. I wish him the best.

    In response to your question, the point of my post about Paul Krugman and single-payer health care was that government can not and does not guarantee medical care for citizens. While medical care in the U.S. is of high quality, health care policy is by no means perfect. Many government mandates and prohibitions drive up the cost of medical care and insurance, which drives many to see charity care. A short summary of that is here. Or, if you prefer video, check out John Stossel's special "Sick in America" on-line here. For more detailed articles, see the "Health Policy Primers" section on the right side-bar.

    Beyond damaging health care policy, many people cannot afford medical care because government runs the schools, which sentences the poor to and hence cripples their earning potential. Check out this on-line video (also by John Stossel).
  • Jim
    All the discussion about socialized medicine and talking about European models strangely enough always seems to ignore the huge elephant in the room: they are all unsustainable in the mid term, to say nothing of the long term. Europe is on the brink of an economic disaster.

    How much more are they going to have to pay for health care as their citizen's average age skyrockets?

    Who is going to pay for it, when so much of their population is retired?
  • nub
    I'll throw myself to the libertarian wolves here by saying that I pretty much agree with Shadowfax. This post *is* entirely anecdotal. For every one of these points you could list literally thousands of instances of equally egregious problems with the current US healthcare system. The major difference being that ours costs us more, a lot more.

    While I can see arguments on both sides of the universal healthcare debate, one thing that seems clear is that our current system is broken. Not only is it obscenely expensive, it's also alarmingly prone to error - indeed, prescription drugs currently constitute the fourth leading cause of death in the U.S. So there are some obvious problems we need to deal with, and I have yet to see any convincing arguments that the fix will come in the form of less government involvement. In fact, it seems to me that a purely capitalist free market solution is uniquely UN-suited to the problem of healthcare, since it would always be in the private provider's economic interest to prolong treatment of disease, not cure it, whereas the opposite would be true for a state-controlled system. I'm interested to hear Brian's thoughts on this point.


    Brian replies:
    Regarding the first argument about the points being anecdotal: As I've mentioned before, I consider only two of them to be so. If I understand Nub's argument correct, he considers the points to be anecdotal because "every one of these points you could list literally thousands of instances of equally egregious problems with the current US healthcare system." But that does not make my examples adectotal. What would make a point anecdotal is that it is, well, an adecdote!

    Nub could be arguing the following: It's not a sufficient argument against single-payer to point out a whole bunch of bad things that happen (anecdotes or studies), if one can find similar bad things about a free-market system (which the U.S. is not). I agree, it's not sufficient. But that was not the point of the post. The point was to show that two statements that Paul Krugman so confidently made were untrue.

    Nub continues:
    So there are some obvious problems we need to deal with, and I have yet to see any convincing arguments that the fix will come in the form of less government involvement.
    Can you direct me to a few of these unconvincing arguments? I'm curious. Perhaps I can point you to better ones on the same issue.

    Nub concludes:
    it seems to me that a purely capitalist free market solution is uniquely UN-suited to the problem of healthcare, since it would always be in the private provider's economic interest to prolong treatment of disease, not cure it, whereas the opposite would be true for a state-controlled system.


    I do not understand why "it would always be in the private provider's economic interest to prolong treatment of disease, not cure it." The U.S. and Canada have relatively free-markets in veterinary care. Is this what patients experience when they bring their pets to a for-profit vet?

    Or what about professionals who fix things, which is analagous to curing a disease? For example, plumbers and auto mechanics? What happens if they do not solve your problem?

    And why would "the opposite would be true for a state-controlled system"? Do you have any evidence for this? I could mention that the United States has the best cancer survival rates, but government accounts for 50% of medical spending, so one could attribute that to the government side. Perhaps a comparison of results for Medicare vs. those with non-government insurance?

    But the core premise behind Nub's statement is that physicians get paid per procedure. That's how insurance companies and Medicare pays physicians. So in the U.S., physicians face the same incentive structure from both the for-profit (not free-market!) insurance companies and state-controlled Medicare. And I'd bet the patients with non-government insurance have more physicians to choose from, and can hence find one who is effective.

    But there are other ways to pay doctors. Economist Arnold Kling writes:
    ...compensating physicians for procedures creates some unwanted incentives. In particular, it rewards doctors for doing more procedures. Doctors try to see as many patients as possible who are in their particular "sweet spot:" if you are an orthopedist who specializes in knee surgery, then you try to see lots of people with bad knees.

    Brownlee proposes the alternative of paying doctors a salary, based on the number of patients that they see. However, I would argue that this would create the opposite incentive. Under a capitation based compensation system, a doctor would want to see as few sick patients as possible, because each one takes a lot of time. You will be paid more if you have a large roster of healthy patients than if you have a small roster of sick ones.

    As an economist, I believe that there is no perfect way to compensate doctors. I would like to see experiments tried with different systems than the one we use today, to see if they improve things. But I would definitely not say that shifting to a capitation based salary system would bring nirvana.
    If you're interested in experimenting with different methods, state-control of medicine is not the answer. It stamps out diversity and innovation, and gets captured by special interests at the expense of customers. After all, customers fork over their money to government, who in turn pays physians. As the saying goes, "he who pays the piper..."

    As a thought experiment, consider what would happen if no insurance company paid a bill leless than, say, $5,000. (First, the cost of insurance would fall dramatically, so people would have more money to spend on out-of-pocket medical expenses.) What would happen to how physicians offered their products, and how consumers bought medical care? Consider it, and then check out an answer here. Something that might happen is that providers come up with better ways to bill patients.
  • Snoop-Diggity-DANG-Dawg
    It's nothing but a political power grab. Fundamentally the desire for "universal care" has nothing to do with healthcare itself.

    Once government fully directs healthcare, they'll be empowered not only to charge you whatever they like, but also dictate policy to mold your lifestyle to its liking. We're already hearing the banter about "banning" fast food & forcing people to choose certain vehicles.

    The new nanny-state knows what's best for all of us. Nothing but a power grab.
  • orthodoc
    Okay, Shadowfax. I'll bite. Show me the data from the countries you're talking about. And just for kicks, let's exclude countries smaller than the average American big city - so leave out Iceland, Luxembourg, and so forth.

    Then show me that those countries
    1. provide care to illegal immigrants
    2. provide high level technology
    3. provide funding for research, either at the clinical or basic science level.
    4. don't consider a neonatal death within the first 24 hours, or a birth weight under 1000g, a "Stillbirth."

    Have at it.
  • Chris
    Brian,

    Way to take Shadowfax apart. Certainly he is one of these folks who is waiting eagerly to take your tax revenues for his own medical care.

    Hey Shadowfax,
    Here's another "anecdote" for you. Belinda Stronach, a Canadian MP, came to the US to get the cancer care she needed because she couldn't get it in Canada, or wasn't comfortable with the system.

    http://www.thestar.com/News/Canada/article/256600

    http://www.ctv.ca/servlet/ArticleNews/story/CTV...

    Of course, it's "personal" and her motives can't be questioned due to that. Just remember, she thinks "very highly" of the system, but not enough to use it in a life-or-death situation. Maybe she was denied because they didn't think a liberal MP was worth wasting the funds on? Maybe it's just a case of "All animals are equal, but some animals are more equal than others".

    Please enlighten us.

    Brian replies: Good points, Chris, and thanks for commenting! It's probably worth compiling a list of politicians who seek medical care in the U.S. while advocating more government control of American insurance companies, physicians, and patients.
  • There is a national health system that works well and it should be a model for us. It is France. It is pluralistic with many health plans, national standards for types of treatment that will be paid for, and a national fee schedule that is not mandatory but has incentives for doctors to adopt. I have a series of blog posts describing this system here.

    http://abriefhistory.org/?cat=184

    I even have a post on a possible transition phase from our present system to the new one. Canada and Britain are usually described as a model because of the language issue but they are very poor models. France has the best health care on the planet for a large country and we should learn from it.


    Thanks, Mike.

    Michael Tanner's in-depth study, "The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World," has a five-page review of France's system. Some exerpts:

    The private insurance market in France is in many ways less regulated than the U.S. market.

    French physicians have shown growing resistance to efforts at limiting physician reimbursement with several recent strikes and protests. In the face of growing budgetary problems, future conflict may well be brewing. More significantly, the government has recently begun imposing restrictions on access to physicians. A 2004 study by the High Council on the Future of Health Insurance raised questions about “the legitimacy of the complete freedom enjoyed by health professionals in setting up their private practice.”...

    Valentin Petkantchin, a scholar with the Institut Economique Molinari, warns that
    France is in danger “of joining the group of countries [such as] the UK and Canada, where
    the existence of rationing of health care and waiting lists raises serious questions of access
    to treatments by those who need them.” And some French health professionals have suggested
    that waiting times for care have begun to lengthen.

    ...the French system avoids widespread rationing because, unlike true singlepayer
    systems, it employs market forces. Even the OECD says that the “proportion of the
    population with private health insurance” and the degree of cost sharing are key determinants
    of how severe waiting lists will be. ...

    To sum up: the French health care system clearly works better than most national health
    care systems. Despite some problems, France has generally avoided the rationing inherent in
    other systems. However, the program is threatened by increasing costs and may be forced to
    resort to rationing in the future.

    The French system works in part because it has incorporated many of the characteristics
    that Michael Moore and other supporters of national health care dislike most about the
    U.S. system. France imposes substantial cost sharing on patients in order to discourage
    over-utilization, relies heavily on a relatively unregulated private insurance market to fill
    gaps in coverage, and allows consumers to pay extra for better or additional care, creating a
    two-tier system. This is clearly not the commonly portrayed style of national health care.
  • Tony
    Brian,
    Thank you for verbalizing the definition of "freedom." I find it terrifying that we have have this exercise, don't you? And I've found on other blogs that when someone on the left side of a discussion argues their point, it is laden with condecending tone and words like "deserve." You're not alone.
  • Roger Godby
    Ah, you missed the 6 August BBC News report "Hospitals 'infested with vermin'":
    http://news.bbc.co.uk/2/hi/health/7542718.stm

    There's also the delightful Free Market Cure site:
    http://www.freemarketcure.com/

    Try getting a doctor in Japan, especially in a non-metro area, after 5 or 6pm. I occasionally meet expats who fly to Thailand for serious medical and dental work because the quality and equipment is better, the staff speak English, and certain treatments are offered there but not in Japan, where new procedures are likely held up by red tape.
  • David
    Brian, your reply to shadowfax ranks among the all-time best.

    Brian replies:
    David, thank you so much! Not only for appreciating it, but also for telling me. Such feedback certainly sustains my motivation.
  • Marc
    An interesting exercise

    http://news.google.com/news?hl=en&tab=wn&am...


    See how many positive articles there are versus how many are negative.
  • The plural of anecdote is not data. Get data, and you can have a seat at the table. Thanks for playing, though.

    Oh, and there are 27 *other* OECD countries that have national/universal health care coverage. You might want to cull data from them too, not just the troubled NHS and Canada.

    No system is perfect, and I'll not waste my time trying to defend the NHS, which no American policy-maker is trying to replicate. But if every damn other industrialized country can provide better access to health care and better health care outcomes, then it only stands to reason that we can do the same thing in the US -- and do it better than they do.

    Reply, by Brian:

    From your condescending tone, I can see why you like Paul Krugman.

    In the eight bullet points I listed, only two look alike anecdotes to me. (The first and fifth.) I don't know what your criterion for data is.

    In any case, even if they are all anecdotes, they still disprove Krugman's assertion that governments an guarantee health care. They cannot.

    And even if governments of other countries can provide better access to health care than in the U.S., I am still not convinced that this is a legimate role of government. If a bunch of bureaucrats can figure out a great way to provide health care, why must they force people to participate?

    Most people (who aren't politicians) who have something good to offer create a product or service, and if people want it, they buy it (or donate to it, if it's a charity). Why must people who peacefullly refuse to participate become criminals in such a system? Why must they be forced to participate in something, if it's so good for them?

    That's not how I treat people. That is, I don't force them to do things they do not want. Do you? I do not want my representatives in government doing it on my behalf. Do you? If I did that, I feel like a user, i.e., someone who sees people as merely means to my ends, as if they exist to serve my purposes. That's not my style.

    I can imagine someone answering that "for the system to work, everyone must participate." But I don't buy thay the individual exists for the sake of serving others, "society", "the common good," etc., which is always defined by other people in power. Such service is exploitation.

    So, this "table" you speak of. It sounds like a place where politicians and pundits discuss making rules concerning how doctors, patients, and insurance companies may, or may not do business with one another. That is, what kinds of products they can sell, buy, and for how much. It also sounds like a place where they figure out how much each taxpayer's earnings must go toward paying for a government program, subsidy, etc. If this is the table you speak of, I want no part of it, as treating people like pawns on a chessboard is disrespectful, immoral, and violates their rights to freely associate with others as they please.

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