Arnold Kling  

Health Care Beliefs and "Sicko"

Adaptive Efficiency... Greg Mankiw Steps in it Again...

My latest essay says,

Illness deprives us of the sense of physical safety. Disease and injury are a throwback to the circumstances in which our physical environment is threatening and overwhelming. Thus, health problems tend to trigger our collectivist instincts.

I am trying to apply Douglass North's view that beliefs determine institutions, and institutions determine outcomes.

Last night, I saw the premier of "Sicko." One of the examples in the new Michael Moore film illustrates the role of beliefs.

The case was of an African-American man who died of kidney cancer. His weeping wife had been told by a doctor that there was hope from a bone marrow transplant, but the insurance company denied the treatment. You were left to conclude that the decision was based on profits or racism.

After the movie, I did a quick search on Google and Wikipedia for the treatments of kidney cancer, and I could not find bone marrow treatment. This reinforced the gut feeling that I had during that segment of the movie, which is that the guy's cancer was so far gone that none of the standard treatments was going to work, and the bone marrow idea was a desperate, last-ditch "hail-Mary pass" that had no proven track record of success.

My gut instinct may be wrong--I do not know all of the facts of the case. But certainly there are cases where American doctors try hail-Mary, desperation medicine. My guess is that insurance pays for this sometimes, and Medicare does so fairly often.

In these sorts of cases, my guess is that other countries do not use as much hail-Mary medicine. My guess is that they tell the patient there is nothing more that can be done, and instead try to help the family let go.

Certainly, what happened to the American family was more inhumane. They got jerked around, with the doctor telling them one thing to get their hopes up, and the insurance company telling them something else to crush those hopes.

But this all gets back to the way that beliefs shape the health care system. My guess is that other countries believe that when someone has passed the point where reasonable, proven treatments are available, it is ok to stop throwing lots of resources at the patient and instead use those resources where they are more helpful. In the United States, this runs up against an intense belief in saving lives, an enormous faith in doctors, and a strong desire never to give up.

In this country, we have not really come to terms with the ethical issues concerning hail-Mary health care. Some people even view desperate, last-ditch measures as an entitlement. As long as we believe that, the component of our health care spending that goes for futile care will not go down.

I attended the premier as a guest of Michael Cannon, of Cato. While I was saving his seat and Michael was getting popcorn, he ran into Michael Moore in the lobby. Moore shook Cannon's hand and apologized that footage of Cannon was cut from the final release. "Sicko" has quick clips of opponents of socialized medicine, at which the audience is supposed to laugh. I don't think that Cannon was too disappointed over his failure to make the cut. But it's kind of impressive that Moore remembered.

Speaking at the premier, Moore was mild-mannered, witty, and self-effacing. He made a plea with the audience to reach out to conservatives and Republicans, and when this received a tepid response from his partisans, he expressed gentle disappointment.

I found the movie to be very non-threatening intellectually, because it was so obviously one-sided. Contrasting French yuppies with American homeless people does not really prove anything.

On the other hand, it could have a tremendous political effect. The woman next to me broke down and wept during a scene in which a group of Cuban firefighters salutes three 9/11 rescue workers brought by Moore to Cuba for treatment. My guess is that this woman's reaction to the film was more typical than mine. I tend to be more analytical than emotional, and I distrust film as a medium. In October of 2005, after viewing a documentary that attacked Canada's health care system, I wrote,

I would say that while I enjoyed the film on the Canadian system and I agree with its viewpoint, I come away feeling that one probably could make an equally compelling propaganda film for the other side.

Michael Moore has done that, and the potential damage to the belief system of Americans is something that concerns me. Michael Cannon was taken aback when I murmured on the way out, "I can see how Hitler came to power." I think he thought I was over-reacting. I hope I was.

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The author at MaxSpeak, You Listen! in a related article titled SHORTER ARNOLD KLING writes:
    I actually like AK. My impression is that to him I am radioactive, if noticeable at all, but whatever. In any case, I can't resist a highly selective excerpt from this post: " . . . I did a quick... [Tracked on June 21, 2007 6:00 PM]
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shayne writes:

I haven't seen "Sicko" in its entirety, but I did see selected clips of the film. I have to say my first impression was similar to that of Dr. Kling - Micheal Moore seems bent on challenging Joseph Goebbels' status as history's most accomplished propagandist. Al Gore comes in second or third in this challenge, more or less as he typically does in the political arena.

jaim klein writes:

Sir, Your note is admirable and it took me an unusual amount of time to find something negative to comment on. Then I remembered a neighbor with advanced cancer who was saved by bone marrow transplant. She is still around pestering everybody. I understand she was treated with high doses of chemotherapy and/or total body irradiation to destroy the malignancy and then her immuno system was rebuilt from transplanted cells. I am not sure that these desperate, experimental, frontier treatments are worth it for the patients and/or for society, but it certainly pushes ahead medical science and trains the doctors in extreme technologies. It is a fact that American medicine is one big step ahead of the rest of the world.

Ashley writes:

Yes, "how fortunate for leaders that men do not think."

Chris Vickers writes:

For what it is worth, the National Cancer Institute doesn't list bone marrow transplants as a standard treatment for kidney cancer.

It does mention some experimental stem cell research involving bone marrow transplantation, currently in clinical trials. So if the NCI can be trusted (and I don't know why it should not be, though I am not a physician), then your gut instinct seems to be correct.

Matt writes:

Reading your comment about the cancer patient, it made me think that perhaps the biggest problem is that we force the decision onto insurance companies. People don't like a dollars and cents calculation when it comes to health. But all socialized medicine really does is hide the calculation. As you say, there are far fewer hail-mary attempts, because under socialism they get rid of the most expensive and least successful procedures. So if the market adopted a mechanism for hiding the cost decision, for instance the doctor cannot tell a patient about a treatment until he checks with insurance, people will feel better.

I'm also reminded (probably read it in one of your essays) that doctors who are liked by their patient suffer less malpractice suits, even if they are more incompetent.

Miracle Max writes:

There seems to be a lot of guessing in this post.

Dr. G writes:

You didn't look so hard. Here on the Mayo Clinic website, there's description of kidney cancer treatment options which includes BMT:

It is, as the site says, still considered an experimental treatmen.

theo writes:

Actually, the last several years of terrorism hysteria offer a much better illustration of how Hitler came to power.

Almost all of the countries that are leading America in health care performance (and cost) are trailing us considerably in metrics of authoritarianism.

Keep your eye on the ball, "libertarians".

liberal writes:

Here's a comment I posted over at Max Sawicky's blog...

Mark R. wrote, He first attacks the American belief system, which he defines as "intense belief in saving lives, an enormous faith in doctors, and a strong desire never to give up." Apparently we (or most of us, anyway) should instead embrace austerity as well as shorter lives.


AK is saying we shouldn't throw tons of resources into treatments that are either unproven or aren't worth it from a cost/benefit calculus.

There's nothing "evil capitalist" about that. The fact is that medical care is a scarce resource that needs to be rationed.

A good case in point was a certain bone marrow transplant technique. IIRC it was used with some success with some type of cancer. Then some bright lights decided to try it on a particularly nasty class of aggressive breast cancers.

The therapy (IIRC the actual therapy is super-intense chemo; the transplant is so that you can restore the patient's immune system after the chemo destroys it) was far more expensive than conventional therapy, and much harder on the patient.

Over time, some people lobbied for insurance companies to cover this technique. Particular those wonderful MDs who had staked a good bit of their careers on it and were pushing it despite no real evidence it resulted in better outcomes.

Finally, someone did a reasonably controlled study comparing the more intense, experimental technique to the standard conventional one. Result? By the usual metrics, no added benefit whatsoever.

Turns out that on that one, the score was evil insurance companies 1, MDs 0.

My point isn't to defend insurance companies, but rather that anyone who thinks that all we need to do is nationalize health insurance (which I agree with) isn't seeing the whole picture: to wit, that medicine itself should be nationalized, with the decision of whether and how to treat made in a rational manner. (The current system, whereby treatment is often undertaken without any evidence that it works, and doctors are treated like some kind of high priests, is crazy.)

The reason that medicine itself cannot be delivered on a rational basis without being socialized was described in the excellent article, "The Best Care Anywhere . Briefly, the point is that what we're really after---efficient delivery of good long-term outcomes---cannot be had with a "market" approach because the nature of this particular good leads to unpreventable market failure.

marcus writes:

Oh, come on Arnold. If this is Hitler, then does that make contemporary Canada, England, and France the equivalent of Nazi Germany? Is government health care equal to mass murder? These kind of comparisons are what give libertarians a bad name.

Matt writes:


What do you call euthanizing people who fall on the wrong side of a cost/benefit analysis?

milton writes:

To theo: in what way is the performance of our healthcare system low? I imagine you're thinking of the typical comparisons to Europeans with regard to life expectancy, infant mortality, etc.

One wants to be careful with those comparisons. First, they are aggregated and subject to a fallacy of composition. Second, they don't distinguish healthcare quality from healthcare access. Third, they don't distinguish lifestyle from healthcare. To ascertain quality, ask 'if you had a disease/problem, where would your treatment have the highest likelihood of success?'

American medical innovation is clearly superior to any other country's with respect to this "conditional treatment effect". This, in large part, accounts for the cost (plus the fact that we subsidize the rest of the world's drug prices and medical technology). We just use that quality healthcare to eat more cheeseburgers, and only for those with insurance.

Crust writes:

"My guess is... my guess is... My guess is.... My guess is.... My guess is...."

You do a lot of guessing. Now for the individual case that's perhaps fair. But when you write this:

My guess is that insurance pays for [hail-Mary, desperation medicine] sometimes, and Medicare does so fairly often.

In these sorts of cases, my guess is that other countries do not use as much hail-Mary medicine. My guess is that they tell the patient there is nothing more that can be done, and instead try to help the family let go.

Why is your reader supposed to care what your guess is? I have no idea whether Medicare does more or less "hail-Mary" medicine that private insurance. And I have no idea whether the US does more or less than other countries. I'm not sure what I'm supposed to take away from being told what your gut tells you, with essentially zero argument to back it up. The one explanation you do give is that Americans have an "intense belief in saving lives, an enormous faith in doctors, and a strong desire never to give up", presumably unlike, say, Canadians. But this just raises the same question: why am I expected to believe that? This is an earnest question, not snark.

Crust writes:

Milton: "[I]n what way is the performance of our healthcare system low?...To ascertain quality, ask 'if you had a disease/problem, where would your treatment have the highest likelihood of success?'"

Check out Ezra Klein's Health of Nations series. He looked into the statistics to answer your second question in detail. IIRC, based on medically preventable years of life lost, the US comes out second last among the countries considered for people with insurance (Britain came in last). If you look at the whole population (i.e. including the uninsured) the US comes in last of the half dozen countries he looks at.

PS Apologies for the double post above.

[duplicate removed--Econlib Ed.]

Crust writes:

Links and details for response to Milton:

Ezra Klein's Health of Nations

OECD table (spreadsheet) with Potential years of life lost (PYLL) by country and sex.

In the full OECD, the US comes in second last (i.e. second worst) on PYLL for women (Hungary is last). For men, the US does a little better, beating Portugal, the Slovak Republic, Poland and Hungary.

milton writes:

Of course, many types of diabetes are preventable. But, the occurrence of type II diabetes in the US is not a failure of healthcare, it's a lifestyle choice.

It's difficult to separate lifestyle from healthcare.

milton writes:

upon looking at your link, crust, it appears that ezra's "data" deal either with medical care *distribution* or measures of "face time", MRI counts etc., none of which deal with the conditional probabilities of healthcare outcomes.

Lorenz Gude writes:

I'm an American living in Australia since the mid 70s where we have a good public system which runs for under 10% of GDP. The interesting thing is that we also have a private system of insurance and private hospitals that allows ready access to elective surgery (you have heard about waiting lists in public systems? ) and choice of doctor. I have a heart condition that is controllable with medication and the public system isn't going to operate on me when there are plenty of people who's lives depend on bypass surgery. Fine with me. For ideological reasons they have a hard time being blunt about that sort of thing, but as a blunt socialist doctor friend says - 'it's a bottomless pit - you could spend 150% of GDP and there would still be things you could do." I like knowing that if I fall over or get run over I will get carted off to hospital and not have to worry about a bill - I already paid it with the separate Australian Medicare tax levy which is how it should be in my opinion. I also like having access to the private system if my doctor and I decide that a particular treatment is the best thing to do. I think eventually countries will end up with universal safety net level health care (that happens informally in the US anyhow.) and a private system on top. Medically I don't want to be dependent on either the Cuban or the US system. I think ideology is a positive hindrance when it comes to medical systems and that is why I am happy to pay twice for an apparently irrational and wasteful system like we have in Australia. They are actually complementary and each saves the other from its worst features.

B Dubya writes:

In a disturbingly large segment of the now late middle aged boomer population can be found the deperate belief that they can somehow live forever, if only they can take the right vitamins, beef up on anti-oxidants, cut down on carbs, keep those nasty people next to them from smoking, and push for every type of legislation that makes them feel safe.
The mayor of NYC is a sparkling example of this fearful approach to life and it's attendant mortality.
Guess what. One day, and for some of you some day soon, your body's warrantee will expire, and you will die.
National healthcare will become a tiered system here, just as it is every where else it exists (and Cuber is certainly the template for that) where the more "deserving" get it, and the less worthy get it too, just not the same kind of get it. I suppose most of the leftist utopians see themselves as the obvious worthies who would naturally benefit most from me underwriting their pitiable attempts to ward off mortality.

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