This is completely false.

Both 'longevity' and 'infant mortality' are absolutely not measures if the quality of the healthcare system.

I've lived in Canada, US, Germany, France.

The best healthcare system is by far the US - however - it's very expensive, and it doesn't cover everyone, which are both big problems.

The quality of care for those who are covered in the US is unrivalled.

Of course, don't get the wrong insurance, you could be out o luck, and out on the street ...

1) My aunt is an oncology nurse in a major city. A high percentage of her patients are from Canada, because they can get treated here for their cancer, and are unable to get those treatments in Canada (or can't get them in a timely manner). Of course, these are only the patients who can afford to pay it out of pocket or have supplemental health insurance.

2) My dad developed a rare lung disease and was treated by the VA (which is government run healthcare for veterans of the US Armed Forces). They determined he needed a lung transplant to survive. It took them 18 months to run the tests necessary to determine if he was a candidate for a transplant, and due to the progressive nature of the disease, by the time they were done running their tests, a panel in DC determined he was no longer a viable candidate for a transplant, and sent him off to die[1]. As a last-ditch effort, he reached out to Mayo Clinic, who agreed to see him. They ran the same tests in 3 days, and determined that he was a candidate for a transplant. He got a new lung, and lived for three more years. I strongly suspect the delay in treatment cut his life short, but I'm not a doctor.

I do not want universal healthcare.

[1] People make fun of Sarah Palin and her "death panels", but they're a very real thing no matter what they're called.

Also, I don't think a person on the face of the planet has suggested that the VA would be a good system to model nationalized health care on.

I would be interested in more specifics about this. It's hard to find statistics that provide a clear comparison of quality between healthcare systems.

[0] https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...

The US usually does quite well: often times somewhat better than some countries with socialized health care, usually somewhat worse than some others; it's rare that there's a dramatic difference between it and other first world countries. But, of course, where there is a dramatic difference is in costs: the US often spends twice as much per capita [1].

[1] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

Moreover, the way those costs are distributed is socially destructive in the US in a way that they simply aren't in any other country. No one in Canada goes bankrupt due to medical bills; in the US, roughly 2 million people do a year, and another 56 million struggle to pay their bills [2].

[2] http://www.cnbc.com/id/100840148

And again, all this is for what is, in aggregate, roughly the same quality of care.

This is misinterpreting the data. The vast majority of this is the problems caused by lost income - an inability to work while ill, not because of the medical bills themselves.

EDIT: remove repeated phrase

"NerdWallet Health chose to include only bankruptcy explicitly tied to medical bills, excluding indirect reasons like lost work opportunities." [0]

https://www.nerdwallet.com/blog/health/managing-medical-bill...

To measure the number of bankruptcies due to medical causes, you compute P(bankruptcy|medical cause) - P(bankruptcy|no medical cause). The study measures P(medical cause|bankruptcy).

Here, "medical cause" = "spent $1001 or more on medicine out of pocket". The classic example of a medical bankruptcy is Michael Vick, the NFL quarterback who went bankrupt after going to jail for dogfighting (due I'm sure to his medical bills).

See also McCardle's deeper debunking of it: http://www.theatlantic.com/business/archive/2009/06/elizabet...

Without getting into it here, I don't think McCardle's "debunking" is very persuasive, but you're right that the PNHP study (and thus at least the bankruptcy numbers in the NerdWallet Health report) has serious problems; I hadn't read it, and just as you point out, the PNHP authors conflate numbers to get them as high as possible: around 62%, whereas "when asked about problems that contributed very much or somewhat to their bankruptcy [...] 54.9% cited medical or drug costs". But while 54.9% is lower, it's...not a whole lot lower. Even if the numbers were halved, say, by taking the 29% of people who wholly attributed their bankruptcy to their own medical bills (not their family's), that's nowhere near an order of magnitude different: a million people going through bankruptcy due to medical bills is better than two million but is just as disgraceful, and simply not going to happen in countries with socialized medicine...so I think my original point still stands.

[0] http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf

[1] https://www.nerdwallet.com/blog/health/managing-medical-bill...

whereas "when asked about problems that contributed very much or somewhat to their bankruptcy [...] 54.9% cited medical or drug costs". But while 54.9% is lower, it's...not a whole lot lower.

So what? This number is again not the true figure. The true figure is #bankruptcies in real life - #bankruptcies there would be absent medical causes. The study doesn't compute this.

Nearly 100% of people who went bankrupt could cite that they paid at least $1001 in taxes and could attribute their bankruptcy to that in a subjective survey if they wanted. Does this mean that it's a "damning statistic" and "disgraceful" that most people pay $1001 in taxes?

Furthermore, bankruptcy for medical reasons (like being unable to work - which the study does include) does happen in countries with socialized medicine. These numbers - and the implications innumerate reporters drew from them - are simply indefensible.

It's impossible to determine "#bankruptcies there would be absent medical causes", because it's impossible to determine a number that only exists in a counterfactual. Absent this, subjective surveys give us an approximation that's broadly useful; literally anyone can lie or misattribute just about anything on any subjective survey, but that hardly makes them useless. There's no sense in being interested in "the true figure" exactly unless we have reason to believe that it varies dramatically (say, by an order of magnitude) from our best approximations, and outliers like a criminal millionaire football player are hardly that; what matters is an idea of the impact of medical costs on people's financial security, and the study absolutely provides that.

Exactly what realistically obtainable data could persuade you that medical bills contribute to financial instability and bankruptcy in the US?

The PNHS study showed that among medical bankruptcies, people on average paid ~$17k out-of-pocket on medical bills. Would those people have gone bankrupt even without having to drop that much money on bills? Maybe! It's impossible to know for sure. But here's a study that says 76% of Americans live paycheque to paycheque [0]; what happens when you drop an unexpected $17000 bill on them? You're fighting an uphill battle against common sense, here.

And from the other direction: a blog post with some numbers showing that people do indeed go bankrupt in countries with single-payer or socialized medicine [1]. Based on the blog title and the writing, this is, I suppose, is supposed to be a rebuttal against arguments for the public system, but the actual numbers - exactly as imprecise and subjective as the American PNHS numbers, mind - are 5%-15% instead of 30%-60%. That's still too high and still disgraceful, but a dramatic improvement nevertheless.

[0] http://money.cnn.com/2013/06/24/pf/emergency-savings/

[1] http://www.conservativeblog.org/amyridenour/2013/5/28/yes-pe...

It's impossible to determine "#bankruptcies there would be absent medical causes", because it's impossible to determine a number that only exists in a counterfactual.

If you were correct that calculating counterfactuals is impossible, then the study in question would be trivially wrong. So would all claims of global warming (earth warmed relative to a counterfactual), all macroeconomic claims about alternate policy proposals (bigger stimulus would have been better), VAM for teacher evaluation, pollution impact studies, etc.

Exactly what realistically obtainable data could persuade you that medical bills contribute to financial instability and bankruptcy in the US?

I'd like a model that accurately predicts bankruptcy probabilities in people who had no "major medical cause" (i.e. medical expenses under $1001). Then I'd apply that model to people with major medical cause and compute #actual bankruptcies - #predicted bankruptcies for the group that did have medical expenses in excess of $1001. This is basic science.

You are right that causality is hard to measure. That doesn't mean we take a totally wrong quantity and pretend it's the right thing. We just admit ignorance.

Now your turn. What evidence (if any) would cause you to believe that taxes in excess of $1001 cause at least 90% of bankruptcies and that this is "too high" and "disgraceful"?

Anyway: if you showed me a study that interviewed a statistically appropriate number and distribution of bankrupt debtors and found that over 50% claimed that a high tax bill was the cause of or contributed to their bankruptcy, I'd agree that taxes probably needed to come down.

Still, a tax bill is fundamentally different from a medical bill, in that your tax bill is ultimately a fact of life: it's something you're aware of ahead of time, and the assumption that you have to pay it is baked into the salary you take, and, in principle, into the rate chosen by legislators. You can plan for it and account for it in a way that you can't catastrophe, and outside of extenuating factors, failure to do so likely indicates pretty severe financial irresponsibility if tax rates are at all reasonable. That's probably why people wouldn't be too likely to claim that tax (or groceries, or rent...) caused their bankruptcy - even if a person is living paycheque to paycheque, they might be scraping by, and then wham: suddenly they get diagnosed with cancer or get struck by lightning and half their annual salary goes to the hospital in one moment, they're going to say that those medical bills caused the bankruptcy, not the expenses that they'd already accounted and planned for. Which I don't think is necessarily wrong: if I knock a glass off a table, in terms of blame, my action is what caused it to fall and drop, and chalking it up to gravity or the glass being in the way is somehow wrong, in terms of our understanding of the idea of fault.

A better comparison might be a tax hike causing bankruptcy. And yeah, if the federal government declared that a person with an annual income of 45k (the average of the people in the PNHS study) suddenly owed 17k more in taxes and people went bankrupt trying to pay it and blamed it on the hike, I would 100% be on their side (and yours, I'm guessing). You wouldn't even need to show me a study, to be honest. I would probably also say that instead of taxing these people just scraping by, they should tax the rich instead, who can easily afford it, and use that to subsidize for the poor, which is incidentally how I think health care should work.

No, but they may be a good approximation. P(B|A) is not a good approximation to P(A|B) - P(A|!B), no matter how much you wish it were.

Anyway: if you showed me a study that interviewed a statistically appropriate number and distribution of bankrupt debtors and found that over 50% claimed that a high tax bill was the cause of or contributed to their bankruptcy, I'd agree that taxes probably needed to come down.

So subjective preferences matter more than objective figures (like costs in excess of $1001)? Interesting.

That's probably why people wouldn't be too likely to claim that tax (or groceries, or rent...) caused their bankruptcy - even if a person is living paycheque to paycheque,...

Yes. The person doesn't want to admit that their spendthrift ways are cause of their problems. They instead choose something that they can nominally pretend is not their fault.

I've seen this in action. I know a guy with a $100-200k/year income, gigantic home, second home, third investment property, spendthrift wife, 2 cars, and living "paycheck to paycheck". He's in serious financial trouble, hundreds of thousands in debt. He also blames unexpected medical expenses (probably under $20k) for his troubles - certainly easier than blaming himself.

You seem to be defending this claim, by saying that Warren's criteria are reasonable.

The fact an expense of 40% of your annual compensation should be easy to handle - a 10% savings rate will get you there in 4 years. Americans prefer a risky financial position in order to have high consumption. That's a choice.

I suppose it is disgraceful that so many Americans behave irresponsibly and then expect others to pick up the tab.

5-year survival rate is an extremely misleading statistic. Much of the increase in the US is simply attributable to the fact that we detect the cancers earlier, so that patients pass out of the 5-year window before they die.

This does not make sense. The earlier you detect cancer, the higher is the likelihood that treatment is effective.

5-year survival rate absolutely correlates with 10-year survival rate and 30-year survival rate.

Though it is undoubtedly true that in the long term, we're all dead. That is however not a meaningful indicator of health care system effectiveness.

I meant what I said about AND CHANGE NOTHING ELSE but experience tells me I have to repeat it. Merely detecting it earlier, BUT DOING NOTHING ABOUT IT, will improve your cancer survival stats.

That is a meaningless population unless you are suggesting that providers are working hard to detect cancer and then, having found cancer, choose to not treat it at all.

Here, let me put it into a story.

We're comparing the health care of two countries, A & B. The survival rates of cancer are better in country A.

So researchers study what country A does to get better results. They find that it has a system of early detection followed by slathering people with chicken blood.

Well, you aren't sure if the chicken blood is the right thing, but surely the early detection means people are healthier, right?

No, because . . . ahem, "if you detect cancer earlier AND CHANGE NOTHING ELSE you cancer survival rates will look better."

In fact, country A and country B may be exactly the same when it comes to treating cancer. But because of very real statistical artifacts like https://en.wikipedia.org/wiki/Will_Rogers_phenomenon, it leads to statistics showing the country A is better when people have the exact same outcomes.

Perhaps you think that rubbing with chicken blood is an unfair comparison of the US health care system, because it uses science-y stuff. But measuring outcomes is hard. Lots of things that people naturally assume improve health outcomes (see other discussion on this page about annual checkups) don't. Some things that we assume improve health care outcomes actually worsen outcomes. Radical chemotherapy is the go-to example. And insurance companies were required to pay for it, too, following expensive court cases. (Health care costs were held nearly flat in the US under HMOs, which put a lid of costs but had no noticeable negative impact on outcomes. This pretty much broke their cost containment. They were also unpopular because they said no a lot.)

So figuring out if the US has better cancer outcomes is hard, because the US really puts a big emphasis on early detection, but it might be just early detection which makes the stats look good.

I'm not trying to push a narrative right here. There are a bunch of different health care systems in the world, and the one thing we know about the US system is that it costs more. This is not necessarily a bad thing, because it's possible we are getting more benefit (by pushing new treatments) but it's also something that the US has not explicitly decided to do, neither by policy nor by the invisible hand of a bunch of individual actors in the market.

If you don't detect cancers, that will not stop people from dying to cancer.

The U.S. health system is expensive because it uses a lot of money for some cases that would receive less attention somewhere else. Some of these are difficult cases that other health systems even cannot treat; others are trivial things where the private insurance system spends a lot for some people while there are uninsured people who get no attention for things that could be cured or prevented relatively easily.

The priorities are not necessarily right; at least they are not producing optimal "bang for the buck" in national health - U.S. spends a lot but still people suffer from preventable diseases.

But early cancer detection is one of the undoubtedly good things.

(Infant mortality rate in the USA was lower than in my country in 1950; now it is more than double. Cuba is better than United States, if we can trust the statistics. However, I'm surprised that Canada is not that much better either.)

No it isn't. I'm trying to ram home the statistical point with a counter-factual. I have to say this extreme because some people Just Don't Get It and keep on trying to talk about something else.

A system that ONLY detects cancers earlier will show better cancer survival numbers even if actual outcomes don't change at all. No, seriously.

Let's lay out an actual example.

Alice, Bob, Charlie, and David exist. Charlie has a minor cancer he won't die if. David has a major cancer he will die of.

In Country B, since detection is heavily correlated with the seriousness of cancer, they detect David has cancer, and David dies. Cancer survival rate = 0 of 1, or 0%.

In Country A, they detect Charlie and David have cancer. David dies, Charlie doesn't. Cancer survival rate = 1 of 2, of 50%.

> If you don't detect cancers, that will not stop people from dying to cancer.

No one said this.

> But early cancer detection is one of the undoubtedly good things.

This is wrong. I know your gut tells you this is true. Your gut is wrong.

Increased detection sometimes helps and sometimes hurts. There are a lot of people, like Charlie in the above example, who would never die of cancer, but because of increased detection they now undergo risky cancer treatment. All treatment involves risk, and for cancer treatment this is particularly true. Again, look up the history of radical chemotherapy. The people who underwent it had worse outcomes than people who had nothing at all done to them.

Researchers usually find that people in palliative care do better than people in active treatment. This isn't enough to say that no treatment is always better, but it is enough to say that some treatment is often worse.

Because so many people have your gut reaction, though, "early detection" is a popular way of throwing money at the problem in America.

> Infant mortality rate in the USA was lower than in my country in 1950; now it is more than double. Cuba is better than United States, if we can trust the statistics.

Here's good questions to ask yourself when looking at infant mortality.

1. What's the difference between a miscarriage, a stillbirth, and a dead newborn? Particularly, what does it mean when this answer changes between countries, and even within countries?

2. How do the numbers change if you compare white Americans to white Canadians and black Americans to black Canadians?

There isn't such a system, anywhere. Even if you could have a public health care that detects and tries not to treat, you still cannot effectively forbid people from getting treatment themselves - if you make a law against it, people will try to escape the country to get treatment. So if you have a better detection rate, there will be actions to treat.

>Increased detection sometimes helps and sometimes hurts.

Perhaps the fallacy here is the belief that the helps/hurts ratio of treatment is 50/50? It isn't.

Of course there are cases where the treatment actually made things worse. There are more cases where the treatment has no significant effect.

But it is rather silly to assume that cancer treatments would have a net negative of zero effect.

Regarding the infant mortality rate, the definitions of miscarriage, stillbirth and dead newborn are not so different between developed nations that it would change this. Where IMR is lower, also stillbirth rate is lower, so it's not really about moving the boundary between these.

Good God, man.

The short answer: Whenever death rates plateau for the 99th (or whatever) percentile, relative to progression of the illness. If you wait XX years until the effect of moving around the diagnosis date is largely mitigated statistically, then the error begins to fade.

The long answer: This isn't quite the right question to ask at all, because it assumes away the possibility that the naive "years from diagnosis" is a flawed metric in the first place. The point of the comment you're responding to is that "n-year survival rate (from diagnosis)" as measured is a flawed statistic in general, because the baseline from which the counting starts can be different for people with the exact same outcomes. An illustrative _reductio ad absurdum_ thought experiment here is that of taking two people with the exact same cancer, detecting one earlier, and giving both exactly no treatment (or treatment on the exact same schedule). Despite having identical quality of care and outcome, the person whose cancer was detected earlier will show up as having a better 5-year survival rate, simply because we started counting earlier and her 5-year mark came earlier in the progression of the disease.

This can be mitigated to an extent by controlling for stage of cancer or whatever, and that's probably a good idea, but this is necessarily brittle and hard to scale and study.

Congratulations I guess, but you've just put a bunch of medical researchers out of a job. They had to study a long time to do that job!

I won't hazard a guess as to which argument you're imagining I made, but I'm not seeing how you jumped to this conclusion at all. As Dylan16807 points out below, "deciding which drugs or lifestyle choices make death due to longterm illness more likely" has approximately nothing to do with an apples to oranges comparison of time intervals starting at different points.

In fact, to the extent that attempts to figure this out do involve comparing intervals, they tend to be ages, which by definition are measured from birth. That's pretty much the highest standard for having a reasonable, stable beginning point when comparing time intervals across people's lives, in a way that "years after diagnosis" doesn't approach by a long shot.

> Congratulations I guess, but you've just put a bunch of medical researchers out of a job. They had to study a long time to do that job!

I'm assuming the juvenile tone is an attempt to cover up your lack of comprehension with bluster. "Congratulations I guess"

If I've misunderstood this complex and sophisticated argument and we're all ready to admit that detecting cancer later is worse, then the original point that USA is better than UK in this one tiny respect stands.

-

I'll lay out a particular scenario where this happens:

Currently we detect a cancer moderately far along, and aggressively treat it. The five year survival rate is 50%.

We figure out how to detect it two years earlier. We use the same aggressive treatments, and the five year survival rate is now 70%. Hooray! But looking closer, if we wait another two years to correct for the early detection, the survival rate is only 45%. Only some of those tumors would have continued growing. Of those, attacking early is only marginally helpful. In others, the tumor wouldn't have killed the patient, but the radio/chemotherapy killed a quarter of them.

In this case, we magically know we detected everything two years earlier, so we could look at the seven year survival rate instead of five year. But the real world is not so clean. It's very hard to figure out a timescale and normalize everyone to it.

-

Catching cancer earlier screws up your ability to measure survival. A naive analysis will see higher survival rates when smaller/earlier tumors are detected. A sophisticated analysis that corrects for this is actually hard to do.

Even when you do save lives by treating earlier, it's very hard to figure out how many lives are saved, and how much of a confounding factor your detection method is.

I suspect it would be easier to improve the 5-year cancer survival rates in the UK than it would be to eliminate healthcare-related bankruptcies in the US.

The NHS has also become increasingly inefficient over the last couple of decades, as managerialisation and stealth privatisation have diverted funds away from front-line patient care towards administration costs and third-party profits.