Cost of Health Care By Country, as Compared to Life Expectancy | Hacker News Reader

Cost of Health Care By Country, as Compared to Life Expectancy

good.is

113 pointsalexandros104 comments

I wonder if this controls for various other lifestyle choices.

I find it ironic that the government spends so much money subsidizing high fructose corn syrup, and then spends even more treating the health problems that result from it. If we didn't have an agricultural system that makes unhealthy food cheap and healthy food expensive, perhaps we wouldn't have quite so many obesity-related illnesses.

Same thing with parking lots and interstates being subsidized while dense urban development (walkable/bikeable neighborhoods) is not. Cars kill a lot of people outright through accidents, and then indirectly through people becoming couch potatoes.

Usually by the time people come under care of the health care, the battle's already been lost. Acute, lifesaving interventions on otherwise healthy people aren't all that expensive. Chronic conditions caused by 40 years of neglect are. I'm curious if we'd get both the cheaper health care and the longer life expectancy of European countries if our cities were laid out like theirs and our agricultural system didn't dump massive amounts of subsidies on the corn industry.

Good point...poor lifestyle drives healthcare costs up. It would be interesting to see fast food spending or avg calories/day on top of this chart.

Couldn't agree more and it's a point a lot of people are hush-huse about because it's easier to point the finger at the system than poor personal habits.

just a small sample... http://grab.by/1v6n

Here's the thing, I'm a Canadian who's living in the USA. Canada has much lower health care costs - but our dietary patterns are much the same. In fact, I really have not changed my feeding habits at all since coming to the USA.

Yes, unhealthy dietary choices weighs the system down - but it weighs all systems down, and to say it accounts for the majority of the discrepancy is IMHO missing the gorilla in the room, which is that the US health care system is unbelievably broken.

Addendum: There is one thing where the US is very different from Canada. You guys eat the same stuff we do... but you eat much more of it. I'm pretty convinced that the average American can eat half, if not one quarter what they currently do and be just fine. Serving sizes in the US are so big that nowadays I often pack up lunch leftovers and have more than enough for dinner.

Canadian diet patterns are significantly different from those in the US. As of 2004, Canada had an obesity rate of 23.1%. The corresponding rate in the US (circa 2005) was 34%.

The big difference here is probably racial. Table 3 of my first link suggests white Canadians are only a little thinner than white Americans. But blacks, particularly black women, are considerably fatter than average. They make up about 12% of the US and 2% of Canada.

http://www.statcan.gc.ca/pub/82-620-m/2005001/article/adults...

That wouldn't account for it. Even if every single black person was obese and every single white person was not, a 2%->12% discrepancy in black population could only account for a 10% swing in obesity rates. The rates you cite differ by more than that.

I think that potatolicious's addendum hit the nail on the head though: Americans eat too much food. When I cook for myself or eat at Google, my portion size is about 2/3 the typical restaurant portion. Doggy-bags have always been normal when my family ate out - it's not unusual for a restaurant meal to generate at least another couple lunches and sometimes another dinner. We're not fat. I suspect that a lot of Americans don't realize that restaurant portions are sized to accommodate the biggest conceivable person eating there (serving too little food is far worse than serving too much), and that the typical person shouldn't be eating anywhere near that much.

True, blacks alone would not account for the disparity. As I mentioned, white Canadians are less obese as well.

But the disparity is much larger for blacks. I mentioned blacks mainly because I could quickly find statistics for them.

This is a terrible graph. It took me five minutes to figure out how everything is related. Data such as this is much more naturally plotted as an x-y scatter-plot. Thickness of the datapoints could indicate number of doctor visits. Instead, the graph eliminates the x-axis, but retains the space. Very strange choice.

I agree that it's unfamiliar, but once you've figured out how to read it, it strikingly demonstrates the degree to which the U.S. is an outlier.

My claim wasn't that it's unfamiliar - which it is - but that's it's terrible. What's striking is the data, not the visualization applied to that data. I think the effect would be just as dramatic with an x-y scatter plot, and it would have the benefit of being easier to read.

This graph also eliminates seeing if there is a correlation between money spent per individual and life expectancy. On a scatter plot, if there was a correlation, we would expect to see the data fall in some line. If a data point was outside of that line, then it would be obvious.

the graph gives an important ratio that's hard to capture in scatter plot

age/cost (the slope)

also, how do you identify your datapoints in scatter-plot neatly?

to me this graph gives surprisingly rich information packed

I don't understand your first point; the relationship between two variables is more clear to me from a scatter plot. And that's something else that bothers me about the graph: when I look at a graph with lines, I expect to see trends. But the lines in this graph are actually single data points.

We're on the web, so it would be neat to be able to use the mouse to hover over data points to see labels.

Scatterplots are usually necessary to check correlations. See

http://en.wikipedia.org/wiki/Correlation_and_dependence

for a famous set of example scatterplots first designed by a statistician warning students of commonplace errors in interpreting correlation coefficients.

in the scatter plot this information is more clear to me, also - in the scater plot if I draw minimal squares line, I can immediately see the countries that are "better thhan average" and "worse than average" with their efficiency of healthcare.

Agreed. Here's the same data in a scatter plot (second chart down). Far, far easier to grasp.

http://www.stat.columbia.edu/~cook/movabletype/archives/2009...

Thank you. As I suspected, I can immediately read the scatter plot. And the correlation that I wondered about is indeed there.

The problem with the scatter plot is that you lose the average cost/average life expectancy info. On the original plot, the UK corresponds roughly to average health care costs and average LE. The slope shows if the country is getting value for money. The upward slope of New Zealand shows that they are spending less money per person than the average yet getting better than average results. The downward slope of Denmark shows that they spend more than the average for inferior results. That information is lost in the scatter plot.

But it could easily be added in by having horizontal and vertical lines added that read "average healthcare cost" and "average life expectancy."

IMO, the slope of the lines in National Geographic chart show the Spending/LE relation better.

Actually, this seems like a terrible visualization because it's taken out of context, and was originally presented in a magazine. You can see where the article text would go, the United States label is hidden away near the binding and far in the upper margin, and due to expected info location/"eye drift" one doesn't find the U.S. at first.

Wish I could provide a scan of the page as it went to print, but I only saw it while visiting family. Regardless, the presentation is clearly to cause that double take rather than just to efficiently convey the information.

Graphs are abused.

Graphs are meant to present data clearly and concisely. The most clear and concise presentation method should be used. If it is not, there are reasons to be skeptical.

This graph is not the best presentation imaginable; it's not even mediocre. It is meant to appeal visually to those who already have reached the conclusions it is meant to illicit; it is graph porn.

Health care spending and quality is very complex. What about adjusting for relative wealth (not merely the health care spending share of GDP), lifestyles, racial composition (if I am correct, there are biological differences in addition to the obvious socio-economic ones), preferences (how much would you spend for an extra month), etc. Asking questions like why other countries spend less on drugs (does the U.S. subsidize medical research by spending more or is it merely the one that allows rent seeking or both?)

After doing so, I believe you will still find evidence suggesting that the U.S. system spends more than it should and there can be clearly identified inefficiencies. That is the distilled information that is interesting -- not the merely manipulative.

The research question is one that occurred to me. Do these cost data include spending on medical and pharmaceutical research? I would imagine that the bulk of that spending occurs in those same countries that are "above" the average line in this graph, and could contribute to that skewing.

Doubtful. Medical and pharmaeutical research is done either by private companies or by universities and such.

U.S. patients certainly subsidize drug research. There are frequent calls for re-importation of drugs from other countries because, often, they are identical to the U.S. drugs, but have been bought by foreign governments exercising monopoly purchasing power. It makes sense for the drug company to sell at the discount because the manufacturing cost is so low that it is still profitable. Consequently, U.S. patients, who do not get the monopoly proxy, pay the higher cost.

This often leads to accusations of price gouging. However, looking at the returns on investment from publicly listed companies suggests that they are not charging extortionary fees. There financial figures are in line with that of the tech industry.

Granted, drug costs only one element among many in the debate, but I am pretty confident in saying that if drug costs were uniform, other countries would be paying more and the U.S. would be paying less (relative to current spending.)

Data for missing countries (from a comment written by the author of the original graph):

    HEALTH CARE SPENDING (per person in U.S. dollars)
    Norway: $4,763
    Netherlands: 3,837
    Belgium: 3,595
    Germany: 3,588
    Ireland: 3,424
    Iceland: 3,319
    -------------(OECD average: $2,986)
    Greece: 2,727
    Italy: 2,686
    Turkey: 618

    LIFE EXPECTANCY
    Italy: 81.2
    Iceland: 81.2
    Norway: 80.6
    Netherlands: 80.2
    Germany: 79.8
    Ireland: 79.7
    Belgium: 79.5
    Greece: 79.5
    -------------(OECD average: 79.2)
    Turkey: 72.1

    DOCTOR VISITS A YEAR
    Belgium: 7.6
    Germany: 7.5
    Iceland: 6.5
    Netherlands: 5.7
    Turkey: 5.6
    Italy: no data
    Norway: no data
    Ireland: no data
    Greece: no data

It's a shame the graph misses data form countries like Italy or German, both countries provides free universal health care.

of the three countries that have highest (and surprisingly parallel) slope: japan, south kore, mexico ... it suggests that #visit correlates with LE ... and health coverage is unimportant

but there are countries that have less #visit but more expensive (it suggests patients go to doctor not only for consultation) ... so #visit is an unreliable predictor so is cost

to me it seems the most predictive is location (yes, the country names are data points too) ... if i want to live long, i'll settle in japan and do what the average japanese for their healthy lifestyle

The slope of the line is an artifact of the visualization choice.

I think the slope is the whole point of the graph and it is supposed represent efficiency although in a very unfortunate way. The angle of the slope is defined by arcsin((life_expectancy - healthcare_costs) / constant). It's a bit like subtracting apples from oranges.

If there's one thing I've learned at engineering school it's that mixing up units of measurement is not a good idea. If you subtract years from dollars the value you get will carry no meaning. And that's why this visualisation is completely meaningless. They should come up with a more clearly defined and sane approach.

You could probably get 90% of the benefit of the Japanese lifestyle by moving to a walkable urban environment like NYC, selling the car, and eating the japanese diet. You'd probably have to visit there first to see what that actually is. Any other East Asian diet would be fine as well - hell, a pre-1970s American diet would probably be fine.

I am curious if those life expectancy figures have been controlled for smoking, though. If not - wow.

Why is hacker news linking to blogspam instead of the original National Geographic website?

The blog is copying Clusterflock which copied kottke which credited biancolo who presumably saw it directly from National Geographic.

http://blogs.ngm.com/blog_central/2009/12/the-cost-of-care.h...

Some reasons American medicine is very expensive:

1. Health insurance, but not treatment, is fully tax deductible. So if you buy your own penicillin, it's with after tax money, but if your insurance company buys it, it's pre-tax money. That's one of the reasons that health insurance is so widespred in America even for routine medicine like antibiotics and checkups. That's a major contributing factor in why the administrative costs are so high.

2. There's a shortage of doctors in America, and qualified doctors from other countries are not allowed to practice medicine in the United States. So there's good doctors from Canada, England, Japan, wherever that'd love to practice in the USA, but can't. This artificially inflates doctor's wages by restricting supply.

3. American doctors are typically required to get an undergraduate degree, medical degree, and do a below market, crazy hours residency in order to be able to practice medicine. That's 8-10 years of study and below market working to practice medicine. Now, medicine is very important and needs to be done right, but I don't believe for a second that a focused apprenceship couldn't teach a very specific kind of medicine - say arithscopic surgery - in just 2-4 years under a highly trained doctor, but this isn't an option.

4. The Food and Drug Administration requires new drugs to be proven not only for safety, but also efficacy. That's an incredibly high and expensive burden to meet - that means that drugs need to be proven to work to a certain standard, instead of just not harm. This adds years of development time and millions of dollars in cost to the new drug development cycle.

Those are all legislated reasons that increase the cost of medical insurance, doctors, and drugs. They'd be fairly easy to remove -

1. All medical and health expenses can be written off taxes regardless of insurance. Employees can choose to convert som of their wages to a medical or health plan tax free to both the employer and employee. (Currently, under most circumstances, only employer-provided health insurance can is tax free)

2. Allow any doctor in a country with reasonably competent medical standards to practice in the United States.

3. Require that doctors be able to demonstrate that they can practice their area of medicine capably. Be flexible in how they demonstrate that. Note: This will incur high opposition from medical schools and current doctors who are currently enjoying the wage premium and had to go through the very long, difficult, and expensive system.

4. Change the drug standard from "safety and efficacy" to only safety. Drugs will come to market much faster and cheaper. There's plenty of people and organizations that will test proven safe drugs for efficacy for free or nominal cost once drugs hit market, and efficacy will get understood with time. Put this way - a proven safe but questionably effective treatment against heart disease being held off the market for five years and costing much more to get to market is not a good thing. If it's certainly safe, then let people make the decisions with their physicians, instead of having the FDA take such a strong gatekeeping stance.

Technology has progressed such that we don't need government protection from ourselves as much any more. The current set of legislation has greatly increased the costs of doctors and medicine. Regardless of political position, and regardless of stance on other health issues, addressing these four points will make the medical system fairer, more effective, and and less expensive with relative ease.

Admittedly, there's some powerful entrenched interests that are winning in the current arrangement, and will oppose these simple improvements.

I agree with your overall point that the U.S. medical system suffers from overregulation. We could (and should) allow more primary care to be performed by, for instance, qualified nurses, RNs, and nurse-practitioners. As you point out, the existing guilds hate this idea.

But your first point needs some correction. Health insurance is only tax-deductible when it's paid for by your employer. [EDIT: Just noticed you mention this lower down, but your first paragraph gives a misleading impression.]

This is perverse in multiple ways. There's the way you mention: that it subsidizes health care over other forms of compensation, so we wind up spending more on health care than we would otherwise.

But also, with particular relevance to HN, it subsidizes employment over other kinds of work. If you leave your job to start a startup, you lose a substantial tax advantage.

If you are self-employed you can deduct your insurance as a business expense, Schedule C.

If you are employed but your employer does not offer insurance, ask if they would pay for an individual plan out of payroll withholding. I've done this and it lets you buy insurance pre-tax even if your employer does not have a plan. This is a significant savings.

Look outside the US, and you will find that your solution (primary care done by nurses) isn't unlikely to be the right one.

In France, going to the doctor (general practitioner) costs €22, before insurance (it's €5 or €1 after insurance, the co-pay as you'd call it). It's much cheaper because:

- he didn't have to spend 200k to go to med school, it's free

- he doesn't need 5 employees to fill insurance forms, or waste 2h a day calling insurers -- it's all automagic, no paper involved.

Regarding point 4, what would prevent a drug company from claiming that, say, Aspirin could cure AIDS? I do not think that is a stretch, either. If companies can profit from selling pills to increase penis length, I see no reason why they wouldn't make other claims if they were legal.

I do not trust in the market to correct unverified claims; many people want to believe in miracle cures, and will buy snake oil despite others decrying it as such.

They trust their doctors. In the rest of the world there are not the restrictions on drugs that are found in the USA. Also, what about all the people that could be saved by a medicine that have nothing to lose if it doesn't work since they have no other options -- right now they SOL. The amount of people that die because they cannot receive medicines that may work is staggering and a great injustice.

Do you have data on the number of people who die because the FDA has not approved a drug that may save their life? Note that this is different from people who die because they can't afford treatment.

I would be more comfortable with point 4 if we once again banned prescription drug advertisements.

> Do you have data on the number of people who die because the FDA has not approved a drug that may save their life?

That question wasn't directed at me, but finding out some data wouldn't be too difficult - you'd look up what life saving medicines had come to market since the stricter FDA regulations were enacted, what year the medicine entered trials, how many people died while they were in FDA trials before release. You could come up with some rough numbers for that, but the FDA doesn't post any information on added costs and deaths during trial periods. Obviously the safety trials save some lives, but the efficacy standard the FDA has is extremely high and adds millions and years to costs.

> I would be more comfortable with point 4 if we once again banned prescription drug advertisements.

The tough question is for drugs that people not be aware there's solutions for - erectile dysfunction, for instance. A lot of men just assumed that was something you had to live with when you got older before Viagra came out. Advertising for Viagra was probably a win for everyone involved - it educated doctors and patients that it's available, and obviously men and their partners were quite happy with its effects.

So some advertising definitely has positive benefits, but I see what you're getting at with snake oil claims if the FDA isn't as strict about playing gatekeeper. Something to think more about.

I think the effect of eliminating the efficacy standard would just be to shift the cost from one that is paid upfront by the company and then borne by the consumer to one that is wholly borne by the consumer. The cost of finding effective treatments would not be reduced, but just more hidden in the cost of having the market weed out more medications, misinformation around claims, etc. Just look at the supplementation market which the FDA does not regulate much. How many people waste their money chasing claims that have little or no effect?

In life or death cases, the FDA can grant a Humanitarian Use Exemption. eg. Experimental cancer treatment drug.

The key difference is in the "experimental" part, as that drug cannot be marketed until its fully approved.

The doctor would have to get permission from the patient, and their hospitals "Ethics Review Board"

I believe this is a question often studied in Economics journals, you may want to look there. If I remember correctly, it is referred to as "Type I vs. Type II" error. One type of error is when a drug is approved prematurely and people are harmed because of it. The other type of error is when people are harmed because a useful drug is kept off the market. Some economists theorize that the second type of error would be more common, because the first kind of error is more visual and visceral. I believe there have been studies attempting to find evidence for the theory, but I'm not an expert and have never kept up with the latest journals in economics.

Remember that the FDA in the US only requires that a drug be better than placebo to be "effective" in many cases the drug company just has to show 0.1% better than placebo to get passed.

They need to prove statistical significance. Getting a 0.1% better drug past would require a pretty large control and sample group, making the drug more expensive to continue to test. Also, the doctors are given the drug's effectiveness vs placebo, and no doctor is going to give a drug that give the patient a 50.05% rate of recovery when 50% is the base.

I don't have any hard numbers, but here is a good article from 2007 that may provide insight into the problem.

http://reason.com/archives/2007/07/25/dying-for-lifesaving-d...

In the rest of the world there are not the restrictions on drugs that are found in the USA.

I have lived overseas long enough that I have been treated by licensed medical doctors in another country, who prescribed to me drugs that are not permitted in the United States. That was not a happy experience. I eventually had to have FDA-approved drugs that ACTUALLY WERE SAFE AND EFFICACIOUS sent over to me as I continued my stay in that country. There are prescribing and dispensing biases in other countries that frequently cause the most safe and effective medicines to not even be available in those countries at any price, even long after FDA approval of the best medicines in the United States.

1. The structure of an unstrained free-market medical system is well-suited for rent-seeking rackets. Doctors and hospitals tend to be monopolies. Even with competition, few are competent at choose between competitors, etc. This situation has historically been restrained by modest regulation and by the fact that most people entering health care are motivated by the desire to help others. These restraints are gone.

2. The current situation is neither "over regulation" nor "under regulation". It is mis-regulation. But all the regulation or lack-of regulation in the world won't really prevent a determined group of racketeers/rent-seekers aiming for their accustomed level of sales and profits through their monopoly position. There just aren't enough honest dollars in health care to incentivize the currrent system into being efficient. Making the existing system "work" is akin buying La Cosa Nostra spreadsheets and hoping this will turn it into an honest business. Reform at this juncture is like saying "can't you only restrain the growth in fraudulent loans just a bit". When the housing bubble was high, even the growth couldn't be stopped. Now, the decay can't be hidden.

3. It's not "The Doctors" or "the insurance companies" or "the hospitals" that are the problem but all of these and none these. There are indeed "good parts" and "bad parts" in the drug, hospital, doctoring and insurance industries. But the "bad parts" are far to too adaptable for efforts at restraining them piecemeal to work. From the chart in the article, you'd have to deduce the parasitic parts of US health care get at least twice the sales of the parts needed for a sane health care system and quite possibly four or five times that.

4. The point is NOT how we will correct the excesses of the current health care system. The question is when the growth of the current excesses will reach the point when they are truly unsustainable. The current "reform" wave seems aimed to enlisting the state primarily in the task of squeezing more money out of those who weren't paying into the racket (the uninsured). Well, once they've run of people to squeeze and health care cost go from 20% to 30% of GDP, there won't be any further place for the cancer to go but down. I'm guessing that's five to ten more years. Will our economy last that long? We'll see.

5. There are free market solutions that could work and single-payer solutions that could work. It's shame we won't see either kind of sanity for a while.

I honestly wish someone would reply and refute my argument above, it's so depressing to think about the consequences...

It is depressing. If I am about to die, I will pay whatever you want to charge. And if you collude with others, my negotiating position is toast. In addition, as a free citizen I am always able to invent a treatment that is so expensive that my fellow countrymen can't afford it. That's the nature of being a free person. Yet my fellow countrymen seem to be pretty pissed at this and are threatening to take whatever treatments I might invent and distribute them to the needy. You can call it socialism, but it's also just populist politics.

All this means that traditional market principles don't map exactly in the world of health care (I think they mostly map, just not exactly)

If I am not about to die, but I'm not paying my bills, then you're no longer providing me a service -- you're providing it to whoever is paying. And they're just playing numbers games trying to keep making more than they are spending.

There are some real, serious, foundational problems with health care. None of the current proposals by any party will even begin to fix them. What we're going to end up with, unfortunately, is a situation like every other big political problem -- the politicians will get more votes arguing about it and keeping it broken than they will actually fixing it. So it will remain broken.

Sorry -- not cheering you up so far, huh?

I could spitball some possible solutions. Make it illegal for anybody to pay my medical bills except myself, my family, and charities. Require all doctors to perform 2 years of public health service instead of some of the internships they are currently doing. Have a national standard definition of all medical procedures and require all health providers to publicly post prices for those procedures. Take the percentage of people who cannot afford treatment each year and require all health providers to provide that percentage of free service.

Of course none of that will ever happen.

I will say something political simply because it amazes me: the party who is on television right now demonizing the insurance and pharmaceutical companies is also the party that cut deals with these same industries to limit imported drugs and not have a public option. This virtually guarantees that those industries will be printing money for the foreseeable future. If I told you this five years ago you'd call me a fantastical liar. It's incredible.

Regarding point 3, do most other countries have more relaxed licensing requirements?

About point 3, teh shortage of doctors is not strictly a US thing. I know in Canada doctors often migrate to the US for a better pay, putting pressure on salaries.

Point 1 is not really different in many other countries.

3. could get fixed much more easily by dropping the 4-year pre-med undergraduate degree (http://en.wikipedia.org/wiki/Pre-medical), and adding about 1 year of instruction to med school.

Most of this points (at least 1-3, I don't know about #4) are also true in other countries (like mine). So they are not reasons for why the US health care system is expensive but rather propaganda.

> 2. Allow any doctor in a country with reasonably competent medical standards to practice in the United States.

Not even that. Canada gets many South African doctors (most of which are fairly competent). In addition to this, they continually monitor doctors. So, if an incompetent doctor slips through, he is quickly caught and his license is revoked.

2. There's a shortage of doctors in America

To the contrary, the United States has an unusually high number of medical doctors per 100,000 persons in the population. Economist Martin Feldstein discovered a long time ago, in comparative studies of the United States and Britain, that doctors refer patients to other doctors, so that increasing the percentage of doctors in a country can actually result in more use of medical treatments per patient without any improvement in patient outcomes. After he made this discovery, the United States figured out that promoting the opening of more and more and more medical schools was not going to result in doctors serving underserved areas such as isolated rural areas. (Doctors like to live in communities similar to where their spouses are accustomed to live, as other studies have found.)

The other suggestions in the parent comment have been carefully considered by policy makers around the world and have been found to be policies with some ill trade-offs as well as good, and not just in the United States.

1. I doubt the effect of this is as strong as you seem to think, but ok.

2. There's a reluctance to allow doctors educated elsewhere to practice without undergoing a rigorous accreditation process of some sort in nearly every country in the world except possibly in some of the most destitute third world countries. This isn't unique to the US.

3. All over the world doctors have to train for at least 8 years or so before they can practice. Again, not unique to the US.

4. There's a reason for that. It means the worst quackery is kept off the market. I'd say that's a good thing (also, it's not unique to the US, although the FDA is indeed a world leader in its stringency). Note, however, that the entire world is using (and paying for!) drugs that have been through the rigorous FDA testing process, so again this is not a reason why medical care in the US is more expensive than in the rest of the world.

In addition to health insurance being broken, it seems like most doctors are really terrible in the U.S. I read the other day that it takes on average seven years to correctly diagnose a medical condition. Some diseases, like celiacs, have an average time until diagnosis of 10 years. If you haven't already read How Doctors Think, it's truly horrifying. Unless you have something like strept throat, you're generally pretty screwed even if you have great medical insurance. And I'm speaking from personal experience here; about three years ago I started having some medical issues, and I went into the doctor the day the symptoms started happening. A dozen doctors and specialists later and I still don't have a correct diagnosis. The fact that I'm probably going to have to wait another 5+ years until I can get the problem even diagnosed is complete bullshit. Now it could just be that I have something that is really hard to diagnose, but more likely the reason no one can figure it out is that medical schools have done their best to select doctors with zero intellectual curiosity who never voluntarily read anything about medicine other than pharma pamphlets. Just look at what happened to Shooter because the 'best' doctors couldn't even diagnose something as trivial as lyme disease: http://news.ycombinator.com/item?id=868325

edit: Someone really needs to make a crowdsourced website where you can post all your symptoms and test results, and then offer up a bounty to anyone who can figure out the correct diagnosis.

Someone with even a remote familiarity with the practice of medicine would not refer to Lyme disease, one of the great imitators, as 'trivial'. The rest of your post, though forceful, similarly suffers from having no idea what you are talking about.

Regarding the length of time from the onset of low-risk chronic diseases (unpleasant though they may be), you are right that this is a problem but dead wrong about the cause. The problem is overspecialization and undercoordination. An inherent idiocy in the practitioners would be an easy problem to remedy; the truth is much more pernicious.

"Someone with even a remote familiarity with the practice of medicine would not refer to Lyme disease, one of the great imitators, as 'trivial'."

The fact that it is an imitator makes it easier to diagnose, because a competent doctor will test you for it whenever you have unexplained symptoms. While it's true that the blood tests aren't very accurate, most of the problem is that doctors just don't get people tested in the first place. And even for chronic lyme that is undetectable because it supposedly forms cysts within the cells, there is a new test up to 50x more accurate than the standard test being developed that you can have access to if you're willing to be part of the trial group.

The fact that it is an imitator makes it easier to diagnose, because a competent doctor will test you for it whenever you have unexplained symptoms.

That is a very unfair thing to say, IMO. You cannot just do unlimited blood tests for everyone who might possibly be at risk of $something. Lyme disease is notoriously hard to diagnose and also very rare. It is unfortunate that the case you referred to turned out the way it did. Our medical knowledge is far from perfect, and no doubt it was a learning experience for everyone involved. But it's going way too far to call the doctors "incompetent". If anything it is our entire medical system that remains "incompetent" and calling out individual practitioners is very unfair.

"Lyme disease is notoriously hard to diagnose and also very rare."

It's probably one of the most common, if not the most common, systemic diseases. Any time you have multiple symptoms that can't be explained, lyme is pretty much the first thing a competent doctor would test for. Sorry, but any doctor who heard the list of shooter's symtoms and doesn't instantly think lyme is incompetent. And it's really not that rare, even in absolute terms. Off the top of my head I can think of five friends who have gotten it, and those are only the ones I know of.

I can think of five friends who have gotten it, and those are only the ones I know of.

According to Wikipedia, "the ratio of Lyme disease infection is 7.9 cases for every 100,000 persons". So either you have a staggering number of friends, live in some kind of hot zone ground zero for the disease, or there's some other factor at work.

any doctor who heard the list of shooter's symtoms and doesn't instantly think lyme is incompetent

You talk like Lyme is a solved problem. I do not believe this to be the case. There is a lot of controversy over the condition and it is one of those diseases that people seize upon to explain symptoms they believe themselves to suffer, regardless of medical fact.

Have a read of this: http://www.nytimes.com/2001/06/17/magazine/17LYMEDISEASE.htm...

I'm sorry to hear of your health problems, but unfortunately doctors don't have tricorders yet. It's quite incorrect to suggest that people with "zero intellectual curiosity" are sought out by medical schools, in fact it's a preposterous claim.

We have made great advances in medicine in the past 100 years, but complete understanding of the human organism and its diseases still lies far in the future. Some diseases have no "tests" or definitive diagnostics; they are identified by ruling out other possible causes of the symptoms. This can take time.

"It's quite incorrect to suggest that people with "zero intellectual curiosity" are sought out by medical schools, in fact it's a preposterous claim."

Medical schools are famous for only admitting people who A) went to college B) had high GPAs C) are 'well rounded', meaning they participated in lots of school clubs or whatever. This seems like more or less a recipe for selecting candidates with low intellectual curiosity. And as for empirical evidence, I believe it's also the book How Doctors Think book that quotes the statistic that the vast majority of doctors couldn't name a single finding published in their field's leading journal within the last year.

people who did well in college and had numerous extra curricular interests and activities is a recipe for low intellectual curiosity?

> Someone really needs to make a crowdsourced website where you can post all your symptoms and test results, and then offer up a bounty to anyone who can figure out the correct diagnosis.

Just like that episode of House :) Except in the show most responses were things like "alien abduction" or "this thing my homoeopathic treatment cures". Oh yeah, and there were quite a number of these. How would you solve the swarm of crackpots problem?

Oh that's easy. Create a crowdsourced website where you can post all your diagnoses, and then offer up a bounty to anyone who can figure out the legitimate ones.

I think we should show a chart of each country's health care costs relative to how much their lawyers make on health care related malpractice cases. Because in America, it's out of control, and probably the largest reason health care costs so much.

Honestly, a good first step in taming the health care and health insurance costs should be to cap how much lawyers make on malpractice cases.

Why do people rarely talk about tort reform? I apologize if you did, but I just did a quick browser search for "tort" and "lawyer" and got no results.

Really, why was I down voted? I'm not sure what was wrong with the comment. I think anyone would agree with the idea of tort reform, just like anyone would agree with the idea of health care reform. But even if you don't, I thought that with Hacker news, you only down vote people when they aren't insightful or off-topic. So, a differing opinion also accounts for down voting now? Like on Digg?

Sigh..

Apart from the utter brokenness of the US system, which needs no further proof I guess, this chart says that health care spending isn't very effective at increasing life expectancy. There are other factors, maybe food, that influence life expectancy much more than health care.

I'd imagine that computing the cost of health care is an incredibly complex undertaking. Without being able to review the methodology used, this graph is next to useless. For example, here are just a few questions that come to mind (and I'm sure more would arise if the methodology was properly peer reviewed):

1. Are there no data points between the United States and Switzerland? Are there no data points above the United States and below Mexico? If there are, that would make the graph misleading and they have to specify this limitation if they're intellectually honest. If there aren't, they have to demonstrate that they've gone through the exhaustive list of countries and there are no other "interesting" data points.

2. Is the cost adjusted for cost of living at a given country? If not, that would make the graph extremely misleading. If yes, what adjustment strategy was used? Can we see the ratio between cost of health care and median yearly salary, for example?

3. What does "average life expectancy at birth mean"? Does it account for countries that have a significantly lower birth rate than the United States? I would guess not, which could significantly affect the perception of the numbers. How does one normalize for something like that?

4. How was the currency conversion rate computed? Currency prices fluctuate throughout the year, did they account for that? How much does that affect the numbers? Could be a lot, could be a little, but I need to know whether this was taken into account.

5. What does "universal health coverage" mean? Soviet Union had universal health coverage and no medication, surgery performed by under-qualified residents, and no post-surgery care, unless you know someone or bribe the doctor, of course.

6. Surely there are countries without universal health care other than the U.S. and Mexico - how do they stack up?

7. I'm willing to bet a country like Poland has a lot more homeless people that don't factor into the life expectancy numbers than the U.S. That begs a more general question of whether the same methodology was used for computing the cost or life expectancy for each country. If they simply took official numbers from each country, it's almost certain that they were computed differently. Was this accounted for? If not, I need to know. If yes, how were the numbers normalized?

One could probably come up with dozens of questions like these. Of course any analysis of a problem that complex can be called into question, that doesn't mean every analysis is useless. But before we can seriously discuss this graph, or base any policy decisions on it, they at least have to provide the methodology. It doesn't look like this graph is intellectually honest to me, and the burden of proof is on the author.

A response to the graphic suggests that while "this was evidence of an insane and inefficient healthcare system", "if [they] really wanted a chart that captures what’s wrong with America’s healthcare system, [they] should have gone to the Centers for Medicare and Medicaid Services’ national health expenditures data website and downloaded the figures showing how rampant third-party payment has resulted in consumers directly paying for less than 12 percent of healthcare costs. And when people are purchasing something with (what is perceived to be) other people’s money, it’s understandable that they don’t pay much attention to cost." (http://biggovernment.com/2009/12/29/the-real-healthcare-char...)

I'm sympathetic to this argument given that the American healthcare system is considerably different than many healthcare systems globally in that private insurers acting on behalf of employers (not the users of healthcare) pick up a significant portion of the pie (even if, on a per capita basis, Medicare spending is more than most countries like Canada - though this fact alone begs the question of why the US government wouldn't first seek to fix Medicare).

As a Canadian, the one thing I don't quite understand is how many of my countrymen are so quick to condemn the American system despite all the obvious signs that the Canadian system is unsustainable and failing (http://network.nationalpost.com/np/blogs/fullcomment/archive...). Further, you read about Animal farm like anecdotes (to be fair, I've seen first hand some of this in Canada as well), and you wonder whether or not healthcare systems abroad can really be distinctly categorized between those that are "universal" and "non-universal" given how radically different implementation is - an example from Japan here: http://biglizards.net/blog/archives/2010/01/my_family_the_v....

There are at least 2 other big problems with this graph if presumably it's being used to argue for changes in policy:

(1) The measurement of life expectancy "at birth". The US spends a considerable amount of money aggressively attempting to treat what would otherwise be considered stillborns. (2) The lifestyles of Americans that may have nothing at all to do with healthcare implementation (http://www.usnews.com/health/family-health/articles/2008/04/...) - ie this could very well mean that if the US miraculously grew an entirely public and universal healthcare system as modeled against XYZ country, US life expectancy might not necessarily get any cheaper or better - it is entirely possible that it would become more expensive and worse.

The problem with the Health Care debate is that it's become so polarized that advocates of Single Payer won't admit its failures in other countries while those opposed to Single Payer won't admit we have a problem.

Graphs like this are designed to create a visceral response but rationally they mean very little if not accompanied by an item by item breakdown of why the numbers are what they are.

For example, the Canadian system puts price limits on patented medicines while the U.S. system does not. That has nothing to do with being a Single Payer system but is definitely a factor that contributes to higher costs in the U.S.

Indeed, politics is the mind killer. - http://lesswrong.com/lw/gw/politics_is_the_mindkiller/

Spot on. People absorb some opinion from somewhere - it's almost a cultural, tribal thing. They adopt that opinion. And then confirm it endlessly via Google University's excellent and popular Confirmation Bias program, as demonstrated by the GP's links.

All systems fail, even if it's only rarely. But as soon as they do people seize upon the failure as if it's some kind of conclusive proof of the gut feeling they had all along. They are seemingly completely incapable of thinking in terms of statistics and average, large-scale outcomes. This is, of course, not at all confined to the health care "debate". The situation is so bad that I wonder if some kind of rational risk assessment/statistical thinking course should be introduced in schooling.

Also after a visit to a psychiatrist I found out they charge your insurance more, if you have it, than they would if you didn't. I'm not exactly sure what that was about, but if it was for sympathy, then it just shows that having a bureaucratic insurance company, private or government owned, would still have this problem of distancing the money from the patient.

However I'm still a large proponent of not only life as a right, but healthcare too.

One might argue that (up to a point) this justly represents the cost of administering the patient's insurance claim, whereas the patient who pays cash is only charged the cost of treatment and does not incur any administrative overhead.

Perhaps, but this administrative overhead would likely be existent with a public option too.

Probably so; it depends how much bureaucratic overhead is imposed upon the medical professional. This might seem selfish, but secretarial services ain't free and time spent filling out claim forms is time that could be used in seeing patients.

Then again, you might argue that some medical professionals make so much anyway they should just eat the overhead as a cost of doing business, but that's a different discussion.

It's nothing to do with sympathy. Many businesses try to charge different prices to different consumers based on ability to pay. If you charge a single fixed price, you'll miss out on some sales (to people who'd buy your product at a lower price) and on some profits (from people who'd pay more than you're charging). It's the same phenomenon behind coupons, sales, 'premium' and 'budget' versions, etc. etc. From a provider's point of view, the fact that someone does or doesn't have insurance is an important signal about what s/he'll pay for medical services, and they're rational to take advantage of it.

Well in any case, it my point still stands. They overcharge for insurance. In the end someone still has to pay that extra amount.

What they charge your insurance, and what your insurance actually pays them, are often wildly different numbers.

Ah, spurious comparisons and anonymous blog posts - is there nothing you can't obscure?

The US spends considerable amount of money aggressively attempting to treat what would otherwise be considered stillborns.

I regret to inform you that this particular meme is without foundation. I have had extensive discussions with UK and Euro obstetricians about it and the story that there is some massively divergent standard of care or different administrative classification for births involving medical complications is complete BS, from the same people who go about asserting that family planning is a single step away from forced abortions. The measurement of statistics for things like live births and so forth rely on standardized UN definitions, same as US statistics.

Not sure what you're calling spurious or anonymous by way of blog posts but do you have any references with respect to UN definitions? According to Wikipedia - depending on how reliable you consider them to be (http://en.wikipedia.org/wiki/Infant_mortality):

"The exclusion of any high-risk infants from the denominator or numerator in reported IMRs can be problematic for comparisons. Many countries, including the United States, Sweden or Germany, count an infant exhibiting any sign of life as alive, no matter the month of gestation or the size, but according to United States Centers for Disease Control researchers,[6] some other countries differ in these practices. All of the countries named adopted the WHO definitions in the late 1980s or early 1990s,[7] which are used throughout the European Union.[8] However, in 2009, the US CDC issued a report which stated that the American rates of infant mortality were affected by the United States' high rates of premature babies compared to European countries and which outlines the differences in reporting requirements between the United States and Europe, noting that France, the Czech Republic, Ireland, the Netherlands, and Poland do not report all live births of babies under 500 g and/or 22 weeks of gestation.[6][9][10] However, the report also concludes that the differences in reporting are unlikely to be the primary explanation for the United States’ relatively low international ranking.[10]"

An additional datapoint (pdf): http://repository.upenn.edu/cgi/viewcontent.cgi?article=1012...

Low Life Expectancy in the United States: Is the Health Care System at Fault? Samuel H. Preston & Jessica Ho

Abstract: "Life expectancy in the United States fares poorly in international comparisons, primarily because of high mortality rates above age 50. Its low ranking is often blamed on a poor performance by the health care system rather than on behavioral or social factors. This paper presents evidence on the relative performance of the US health care system using death avoidance as the sole criterion. We find that, by standards of OECD countries, the US does well in terms of screening for cancer, survival rates from cancer, survival rates after heart attacks and strokes, and medication of individuals with high levels of blood pressure or cholesterol. We consider in greater depth mortality from prostate cancer and breast cancer, diseases for which effective methods of identification and treatment have been developed and where behavioral factors do not play a dominant role. We show that the US has had significantly faster declines in mortality from these two diseases than comparison countries. We conclude that the low longevity ranking of the United States is not likely to be a result of a poorly functioning health care system."

Not sure what you're calling spurious or anonymous by way of blog posts

Your first paragraph, which compares apples with oranges (ie 'don't look at that graph, look at this completely different one instead) and your third paragraph, from someone identified as 'Sachi X'.

As for the reporting requirements, if you go look at the actual CDC report (http://www.cdc.gov/nchs/data/databriefs/db23.htm) you'll see that not only do these (minor) differences have much impact on the overall life expectancy statistics - even when corrected for, the US still lags - but the main reason for the skew is the much higher rate of preterm birth in the US - children are much more likely to be born prematurely in the US, with all the medical complications that usually entails.

In short, the CDC report you refer to still concludes you are medically better off being conceived and born in Europe than the US, and does not support your contention that the inferior standing of the US in tables of life expectancy or infant mortality is the result of statistical abuses by scurrilous foreigners.

As for your additional data point on life expectancy, this is interesting and indeed I agree that some of the US mortality differences have more to do with lifestyle than healthcare; however, 'using death avoidance as the sole criterion' conveniently ignores what this thread is about, namely the abysmal cost-benefit ratio of American healthcare.

Listening to just the Euro OBs seems no better or worse to me than just listening to the US OBs. I was initially going to suggest that you also speak with US OBs, but then realized that it's not really possible to just decide to do it one morning without purchasing expensive tickets, etc. But I do hope that you'll agree that the pitfalls of one-sidedness apply to both sides.

Regarding standardization, it does not seem to me to obviate the problem of comparison between unequals in this case. I know you are familiar with these concepts since you referenced them, but I will provide them for other readers; here are the WHO definitions relevant to neonatal mortality:

"The neonatal period commences at birth and ends 28 completed days after birth.

Live birth refers to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life - e.g. beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles - whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born."

The key is that live birth counts irrespective of the duration of the pregnancy. Viability begins around 23 weeks with extraordinary measures (give or take, depending on how aggressive your care may be). Depending on your approach, aggressive care may improve such statistics (if the care is aggressive only after live birth), or worsen such statistics (if aggressive care also occurs prior to live birth and includes things such as induction).

So (a) I think it's actually quite a muddled issue, and (b) I could see aggressive care pushing these stats either way, depending on the timing and methodology of care. It's a legitimate issue that well-meaning people are interested in (in contrast to those who feel that family planning is a step away from forced abortions, who are simply ideologues).

I was initially going to suggest that you also speak with US OBs, but then realized that it's not really possible to just decide to do it one morning without purchasing expensive tickets, etc.

I live in the US. I meant to point out that I had talked with euro and UK OBs in addition what I know from living here. More in my other comment.

Canadians' responses to the US are not a rational phenomenon. They're rooted in our identity issues and aren't amenable to argument. This is a (the?) fundamental fact of (English) Canadian history right from the beginning.

It doesn't follow that all our responses are wrong; as far as I can tell they tend to fall along a spectrum. But it's a real weakness that we can't be more objective. It leads us to accept and defend substandard things about ourselves that we could otherwise set about improving... your example being exhibit #1.

Oh I must be stupid. I spent a good three minutes trying to find where the United States was because I scrolled down.

That's an awesome and persuasive infographic. In fact, it's main fault is that it's trying too hard to be persuasive. Putting the US above the legend detracts from the power of the raw data and strikes me as being unnecessarily editorial.

It's not that awesome when you remember that correlation does not necessarily equal causation.

It's not about showing correlation. It's about showing that we're not getting what we're paying for.

This graph basically proves that the bottom end of American society has fall off and says nothing about the quality of care that the majority are getting.

As others have pointed out, life expectancy is only a single facet of the health of a nation and with many sociological factors such as the fact that americans eat too much which leads to heart disease which is not-incidentally the most common cause of death in the USA.

Assuming you have coverage, what you're paying for is word-class care with minimal waiting times.

It fails to definitively show that we're not getting what we're paying for because a graph such as this only shows correlation.

You are correct. But, If Americans are paying (av. 7k) per year on health and have a lower life expectancy that other industrialized nations, the data alone suggest Something is going very wrong. Strange that it has some of the highest paid doctors and most profitable health care companies also. Surely there must be an explanation study somewhere? http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doc... http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=103622972.h...

it's because the y axis is linear ... i don't sense any overdoing

The way the UK hits just at average (for cost and life expectancy) appears to almost make that look intentional.

Mexico is in red, which I suppose is "technically" accurate, but the Mexican Constitution guarantees health care to all citizens:

http://en.wikipedia.org/wiki/Health_care_in_Mexico#Public_he...

This is just one of many reasons to not startup/move to the US. Don't buy the hype.

This is a great infographic with a high data-to-ink density.

False. The data in this "infographic" is really best represented as a scatter plot, using much less ink, as shown in [1] and similar other blog posts. The lines are unnecessary and misleading.

It's good that Tufte has made concepts like data-to-ink density popular. But I urge you to actually evaluate that value when you look at a graph and refrain from using it to merely signal your knowledge of the right buzzwords.

[1]http://www.stat.columbia.edu/~cook/movabletype/archives/2009...

it's a great graph to illustrate how f-up healthcare in US is.

however, may I point out that life expectancy at birth is pretty poor measure of healthcare efficiency.

japanese are living very long lives, but it is no secret that depression and suicide is the major problem there, especially in younger generations.

Go Obama Go!

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