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Thursday, April 16, 2020

Cherry picking examples to claim that the US health care system "is still the best" when it comes to pandemic response: conservative columnist Marc Thiessen

When DC released its Sustainability Plan during the Gray Administration, in 2013 I wrote my longest post to that date ("Realizing all aspects of Sustainable DC: it all comes down to chickens...") making the point that to be the most sustainable city in the US, the city would have to put in practice "the best practice" in each of the functional areas.

Instead, most of what the city has introduced in sustainable practice tends to lag best practice pretty significantly, compared to what leading cities in the various functional areas are already doing.

E.g., a couple years ago DPW announced it would start compost and yard waste pickup, but in 6 years. etc.

Only two DC sustainability policies were early best practice: the charge for plastic bags, in 2012; and DC Water's use of waste in effluent to generate electricity, to reduce waste products and to improve the quality of waste converted into fertilizer and compost.

DC takes credit for having so many LEED certified buildings, but that was a function of timing of construction during the recession. And in ordinary times it has high rates of transit use, but that's a function of the city's urban design which dates to 1791 and its relative compactness and density, not so much active promotion by city leaders ("DC as a suburban agenda dominated city").

While much of the commentsphere criticizes the Washington Post for being "very left," they do carry a number of particular right wing columnists, in particular Gary Abernathy, Hugh Hewitt, and Marc Thiessen that would fit right in at the New York Post or Wall Street Journal, but there are others besides.

Generally, I don't read any of them, but from time to time I delve into a column or two just to piss myself off.  Most recently, I read Marc Thiessen's column about "Why this pandemic is an indictment of socialized medicine." From the article:
While the federal government’s pandemic preparedness was sorely lacking, the fact is America’s system of private medicine has left us far better positioned for today’s crisis than other nations. As Scott Gottlieb, former commissioner of the Food and Drug Administration, explained in an interview, here in the United States, “we’re going to have a better experience [with this pandemic] than a lot of other countries because of how good our system is at delivering critical care.”
There is a great takedown of the poor argumentation of law professor and self-described "contrarian" Richard Epstein's article about how the coronavirus is no big deal.  The author made the point that what we should be aiming for in discourse isn't being contrary, but using evidence, experimenting, and testing, with the aim of generating the best, most robust answers.

That point can be made equally when looking at the writings of people like Marc Thiessen.


Or Gary Abernathy, whose latest piece, "Our elected leaders need to reclaim control from the doctors," fails to acknowledge that it was the political leaders deliberately not listening to the doctors that has got us to the place where we are, with tens of thousands of needless deaths and infections and a significant closure of the US economy.


Although to be fair, Thiessen does criticize the federal government's failures in terms of testing and making sure critical equipment was available.

But the reality is that the nations of the world that have done the best job in terms of response to the coronavirus, even if there have been mistakes, have been countries with public health care systems.  They can be a mix of public and private facilities, but ultimately there is universal health care coverage, paid for through taxation.

Crematorium Temple of Piacenza saturated with corpses awaiting cremation due to the coronavirus emergency (23 March 2020).  Photo: Claudio Furlan/Lapresse.

Yes, "socialized medicine" didn't "stop the virus" in Italy.

But the issue really isn't as much about private vs. public health care in this situation as it is about public health and the public health response.

Both Italy and the US failed.

But in terms of health care outcomes, the differences between Italy and the US aren't so much about public vs. private healthcare as much as they are about the relative wealth of the two nations, the respective public health failures, and the "luck of the draw" in terms of the timing of "spreading events" ("Soccer match in Italy linked to epicenter of deadly coronavirus," Boston Globe) before most places started instituting stay at home directives.

In the US, Ohio is touted for being one of the earliest actors in putting restrictions on public events, to great effect ("Did Ohio get it right? Early intervention, preparation for pandemic may pay off," Washington Post).

"Wawa donates refrigerated truck to help New Jersey store bodies of coronavirus victims," Philadelphia Inquirer. Photo: Elizabeth Robinson.

Similarly, the City of San Francisco's early stay at home order has had dramatic effect.  SF, with a bit more than 10% of the population of New York City has 17 deaths from the coronavirus, while NYC has almost 11,000.

When it comes to comparing the US, which has a privately focused health care system ("Profit over people, cost over care: America's broken healthcare exposed by virus," Guardian) to countries that have a public health care system, rather than compare the US to other countries that are similarly failing in coronavirus response (Italy, Spain, France, UK--almost 13,000 deaths so far, which doesn't include out of hospital deaths), why not compare the US to other countries that have public health care systems that are succeeding in responding to the coronavirus?   .. with success defined as relatively few deaths.

Examples would be Ireland ("Why is coronavirus killing so many more people in the UK than in Ireland?," Guardian) which has 365 deaths so far, and the count includes out-of-hospital deaths, which many nations are not counting; Canada (1,010 deaths), Germany (3,800), Greece ("Greece has won a battle against COVID-19 but war is not over: PM," Reuters), Japan, South Korea, Taiwan (6 deaths), or even Australia?  Plus, Singapore (but it's an outlier in terms of being small, a city-state, and heavily authoritarian).

And Britain's failure isn't because of "socialized medicine" but because of political failures and how the government's austerity practices over the past ten years have severely underfunded the National Health Service, public health, and aging care.

Conclusion.  The US response to coronavirus hasn't demonstrated that the way health care is organized and funded in the US is superior to national health care systems in other countries, either fully public or a mix of public and private services.

It's not enough to say "we're the best."  It's to be the best. 

And the way that for most people health insurance is linked to employment shows how this completely blows up in a Depression event when people lose their jobs, and therefore, lose their health insurance ("Why a frayed safety net tests the U.S. coronavirus response," Christian Science Monitor).

Similarly, the US failures in public health management and execution are a function of underfunding and the diminishing respect for science and technical advice on the part of elected officials, especially the President of the United States, as well as a general failure to invest in pandemic protection and public health more generally.

11 comments:

  1. charlie12:38 PM

    couple points:

    1) COBRA contention of health insurance/ I think congress extended it and likewise furloughed workers retain benefits

    2) I'd say the US hospital system has responded very well. The decentralization is helping. Doctors are being far more proactive than health care professionals.

    two examples:

    a) centralized hospitals; this is the issue in Italy, don't rally have that in the US. Once a hospital gets the virus it spreads to everyone and you don't have backups

    b) ventilation; based on China (and their own biases) Italian doctors were over-using ventilators and steroids. Steroids work to keep inflammation down but are immusupprentants which kill people. US doctors are finding better results on patient with low 02 levels by NOT putting them on ventilators.


    3) The virus play to US weakness; ironically the best thing you can do is keep 99% of your patients OUT of the hospital setting.


    The biggest weakness being shown is supply chain issue, relying on LabCorp/Qwest.


    Also I'd say you can't make real calls right now, we are in the 2nd inning, and you can see with hospital layoffs the finance of healthcare has disintegrated. 40% less patients across the board. I can't imagine how many people are dying of heart attacks in non-virus hit areas.

    https://www.medrxiv.org/content/10.1101/2020.04.08.20057794v1.full.pdf

    scroll down to figures 2a and 2b.

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  2. Yep, with the excuse of aiming for simplicity, I ignored COBRA.

    2. good point. Many tens of thousands of well trained physicians and well run hospital systems, backed up by medical schools.

    Alongside a lot of underfunded hospitals and overwhelmed hospitals in cities and rural areas.

    3. WRT virus playing to the strengths of our weaknesses, excellent point.

    I didn't mention the hospital finance issue, but it's been on my mind.

    Something is really wrong when the system is so dependent on the here and now revenues, and in a case like this, those revenues dissipate.

    A few weeks ago, before the more recent announcements, Intermountain Health System here announced they'd be reducing incomes for personnel affected by the revenue decrease from cancellation of various procedures in lieu of dampening demand to save room for coronavirus patients. It caused a lot of reaction, but it was just ahead of many other similar actions.

    WRT second inning etc. Yes, unfortunately. All the talk by the conservatives about lying about death figures besides, the real issue is the number of deaths for this period compared to the same period in previous years. Deaths are up significantly in places like NYC. Probably not SF.

    It's a "natural experiment." DK if you are familiar with papers written about smoking ban laws. Some jurisdictions put them in, then they were overturned by state legislation. (Of course, by now, most places have such bans.)

    https://www.sciencedirect.com/science/article/pii/S0273230014001287

    Epidemiologists compared the before and after and found significant increases in deaths after the end of the bans.

    Even though the numbers were challenged by later meta analysis, even a 5% increase can be significant. Same goes now with increase in other deaths due to a lack of resources/resources being diverted to dealing with covid19.

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  3. thanks for the cite. Interesting.

    2. forgot to respond to the supply chain issue you raise. Yep, yuuuge as Trump would say.

    Weeks ago I read in a WSJ article about a German car parts manufacturer with plants in China. They realized they wouldn't be able to source enough masks for their employees, where new rules required them to wear masks.

    So they bought a machine for making masks, with a rated volume of 100,000/day and began making their own.

    Like the response by small businesses and others to make shields and masks, sometimes using 3d printers (that's got to be expensive), it is innovative at some level of out of the box thinking.

    Just read an interview with the CEO of Rite Aid in WSJ. Not scintillating, but she made the point that going forward, people were likely to keep larger stocks of TP, sanitizer, toothpaste, etc. on hand, moving away from household JIT.

    As long as you have attenuated supply chains and an inability to significantly increase production, you're going to have to build more room for slack in the system. Like those US owned vaccine production plants (which aren't contributing), or having a bunch of mask making machines, etc.

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  4. charlie2:51 PM

    haha, I love that German response.

    Two big heath care systems in CLE; UH and the Clinic.

    My dad works at UH. doctor in practice was sick and worried about being infected, could not get tested in UH. Went to the clinic, where they had developed and used their own lab equipment, and was tested in 2 hours.

    So like that German company, winner are the ones who can do that.

    Management consultant speak: Competence is cool.

    The actual death rates are staggering low given obesity as the major driver. I mean they are low, but when you take into account how fat Americans are they are really low.

    (death rates in Louisiana is about what I'd expect. So maybe the "luck" is NYC being the only real hot spot, and they do have a lot of medical resources there.)




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  5. I think what screwed up the East Coast, although granted the Massachusetts problem derived in large part from China, was carriers from Europe. We all were looking towards China/Asia.

    But yep, the big issue is places of extreme poverty.

    What's happening in New Orleans, Chicago, or Detroit is not unlike what Eric Klinenberg wrote about concerning the high rate of heat wave deaths in Chicago--isolation, age were key factors.

    https://www.press.uchicago.edu/Misc/Chicago/443213in.html

    Yes, NYC has lots of great medical resources. Theoretically, Detroit does too, although the DMC doesn't compare to the Cleveland mwedical ecosystem. But it's been overwhelmed.

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  6. whoops, re-reading. Your point on supply chain was lab testing, and I responded thinking about PPE, ventilators, reagents and other components of testing kits, drugs, etc.

    Both.

    insert snarky joke about Elizabeth Holmes here.

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  7. charlie8:33 AM

    RE: supply chain. it's the same. Places that will do well will figure this out.


    RE: US medical system. What you're really seeing here is the massive irrelevance of the medicaa insurance system. The system (insurance) was set up as a risk pool, but moved beyond that year ago. As I've been saying for year, Obamacare was a last ditch effort to keep insurance companies front and center.

    We are seeing their real role -- which is the limit access to the system. Nataionalized system are being upfront on triage. IN pace in France, Italy, Spain and the UK.

    Insurance companies are doing great here right now, because elective procedures are way way down, and magically heart attacks and strokes are also down 40%. RX sales down 25%. Either American got very health in the last month or people with chest pains are afraid to go to the hospital.


    Larger point -- insure companies are mostly about limiting access and payment systems. We don't need them.

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  8. It's been a long time, and I've probably mentioned this before, but c. 1989, working for CSPI, I exhibited at the Academy for Health Services Marketing. I don't know if it still exists. It was/is a division of the American Marketing Assn.

    Anyway, I was shocked (at the time) to discover that they were interested in marketing their hospital systems--getting more admissions--not promoting better health behaviors.

    I think I then learned that health insurance was created to regularize the income of hospitals during the Depression. It wasn't about achieving better health outcomes.

    I think you're right about Obamacare. I was arguing with my brother today about covidetc. -- he is more aligned with your thinking than mine, i.e.,. flu+.

    I said yes, Obamacare hasn't resulted in a decrease in the use of hospital emergency rooms. But that's because it needed to be implemented through a new kind of primary care-public health oriented set up for areas of impoverishment (cities and rural areas). The family/local physicians. Set 'em up like CVSs in W7 and W8. Etc.

    wrt covid19, it appears that the greatest susceptibility has to do with preexisting conditions, and many of these chronic conditions are behaviorally related (CSPI was focused on nutrition and alcohol consumption primarily, at least back then).

    Universal health care per se doesn't address that necessarily. Rejiggering the provision of health care does.

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  9. charlie10:06 AM

    RE: emergency rooms

    Yes, this is what I'm saying about front end vs back end.

    On the back end, US healthcare system may be best in the world.

    On the front end, we've set up an elaborate charade act involving insurance and billing to make sure you can't actually talk to a doctor. Hence why emergency room use is still so high.

    (in a socialized system, you just wait. And for 75% of complaints the problem goes away).

    Obamacare did very little to change that. If you're on medicaid and under 65 you probably don't have a relationship with a doctor that you can call when something goes wrong.

    There are hundreds of factors I could walk through. No enough Doctors. Low compensation for office visits ($50). If you go to an emergency room w/ no money they still have to treat you. Majority of uninsured don't need medical care. so you can push it off. Public health intervention (eat more fiber, don't smoke, don't drink so much) aren't very useful to do with doctors and nurses. People are willing to pay thousands for pets for nothing for themselves.

    As the consultants say, misaligned incentives on the front end and very little ability to change that in a panic. The entire country is seeing that now. Good luck seeing an actual doctor unless you are literally bleeding out your ass. (Blood loss will kill you in about 12 hours).

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  10. charlie4:28 PM

    offtopic:

    https://www.nytimes.com/2020/04/17/business/dealbook/illinois-pension-coronavirus.html


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  11. 1. Besides the CSPI experiences, my interest in this topic has been spurred by city debts around hospitals, poor health and other outcomes of the impoverished, the impact on DC area hospitals from this.

    ... especially PG Hospital. It was collateral damage from outmigration of DC residents to PG County as a result of Hope 6 public housing reconstructions.

    I have a piece from 2006 about the then new CVS Minute Clinics and how that model ought to be used as a way to reconfigure how basic primary care is delivered in what we might term today as "primary care deserts."

    And yes, the only way to address them is to change "the incentive structure," which is something I wrote about here:

    http://urbanplacesandspaces.blogspot.com/2013/07/when-problem-is-defects-in-structure-of.html


    2. Scary s*** with the pension overhang.

    Theoretically, yes, the federal government will have to bail out states, cities, and counties, depending.

    Given what's happening these days on the Republican side with regard to states and localities and hospitals concerning the coronavirus bailout, I can't see this on happening any time soon.

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