Monday, May 04, 2009

What are We 'Best' At?

Over at The Corner, Jonah G publishes this little gem from a reader:
Senator Specter... You went to Canada for all your cancer treatment, right? RIGHT!?
It's pretty standard for wingers to boast that we've got the 'best' healthcare system in the world, but without getting into the mess of public vs private vs single payer vs insurance companies, it's worth thinking a bit about what 'best' means.

When it comes to healthcare, 'best' doesn't actually mean most effective or efficient, neither of which describes the American system. Instead, 'best' essentially means 'we can do things no one else can do'. This definition of 'best' isn't limited to healthcare, and probably stems from America's deeply engrained sense of exceptionalism, and is so deeply engrained that a lot of people don't even realize how much it influences their argument.

When I was debating healthcare with my parents a few months ago, one of my mother's arguments was something along the lines of "the first open-heart surgery was in America", which was supposed to be an argument for our system's superiority. What it really is, though, is an argument for the above definition of superior. No one's arguing that our healthcare system can't do amazing things; it certainly can, and all else being equal, I would like to be able to do amazing things. But what I and other reformers are arguing is that all else is NOT equal, and that our focus on the amazing is coming at the very real expense of the non-amazing. We have state-of-the-art technology, wonder drugs, and miracle treatments ... but we also have 1 out of 5 people going without any kind of healthcare at all. These two things are not independent of each other. Healthcare resources are scarce, not infinite. If you use them up on extremely specialized and expensive treatments, that comes at the expense of other, more standard treatments.

For a very personal and tragic example, look at Natasha Richardson. It's widely known that the technology to save Richardson's life exists, and if it had been used, she would probably be alive today. Winger blogs have trumpeted the fact that the Canadian system failed her as proof that the American system is superior. But it's just not that simple. The technology that could've saved Richardson's life is expensive, about $20,000 per use. And Richardson's specific condition is very rare, about 1 out of 1000 people who suffer similar injuries have it. So the cost of saving just one life isn't $20,000, it's $20,000,000. And every $20 million you spend saving one person's life is $20 million you don't spend on other people. Canada could spend that money saving one person's life, or it could spend that money providing diabetes treatments worth $2K to 10,000 of its citizens. The Canadian view is that it should be spent improving the quality of life for 10,000. The American view is that it should be spent saving the life of 1. Both of these come with their benefits, and their tradeoffs.

Of course, simply understanding this really doesn't make the issue any easier to grapple with. How do you possibly say that the discomfort of 10,000 people is or isn't worth one person's life? And even though these procedures are terribly expensive today doesn't mean they always will be, nor that they aren't valuable. Polio vaccine was extremely expensive and unreliable when it was first developed decades ago ... now it's part of the standard suite of vaccines all children get as they grow.

But even if understanding isn't sufficient, it's still necessary. If you argue in favor of expensive specialization to treat rare and complicated conditions, you have to be candid about the fact that it's coming at the expense of basic healthcare for millions of people.

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