It's a Mystery!

CNN's SiCKO analysis concludes:

As Americans continue to spend $2 trillion a year on health care, everyone agrees on one point: Things need to change, and it will take more than a movie to figure out how to get there.

Yes, it will. We could, for example, read the earlier sections of the article. For example:

The United States spends more than 15 percent of its GDP on health care -- no other nation even comes close to that number. France spends about 11 percent, and Canadians spend 10 percent.

France . . . Canada . . . cheap . . . but does their health care suck? Well:

Like Moore, we also found that more money does not equal better care. Both the French and Canadian systems rank in the Top 10 of the world's best health-care systems, according to the World Health Organization. The United States comes in at No. 37. The rankings are based on general health of the population, access, patient satisfaction and how the care's paid for.

So, okay, it's not that hard to figure out. France and Canada both have two difference systems of health care delivery both of which are cheaper than the US system and both of which are more effective. What's more, these aren't obscure countries. Lots of people have heard of France. Lots of people have heard of Canada. How hard is it for them to just write the words "Michael Moore is right; American health care would be improved if we adopted French methods instead"? Their articles supports the claim 100 percent. Instead, we get this Andrew-pleasing nitpicking about how Moore didn't talk about Medicare. What should he have said? Talked about its low, low overhead costs and high levels of patient satisfaction?

Comments

Re Medicare

Unfortunately, the Medicare system is going broke.

Posted by SLC | June 30, 2007 10:58 PM

Clearly it would be impossible to allocate more money to Medicare without destroying the system entirely.

Posted by john | June 30, 2007 11:37 PM

I have to defend the CNN tagline somewhat. I know that New Zealand is a nice place, but just knowing that doesn't tell me how to get there. Just granting that the French healthcare system is preferable to the US system doesn't really give us any idea how to actually change the US system to be more like the French system.

Perhaps that is what they meant.

Posted by matt wilbert | June 30, 2007 11:39 PM

Well, the first step in doing is that is psersuade the American public that the French system IS preferable to our current system -- as opposed to their continuing to swallow the health industry's propaganda that "America has the finest health-care system in the world". To the extent that that fat caveman Moore does that, he really has managed to perform a public service.

Posted by Bruce Moomaw | July 1, 2007 1:02 AM

This sort of post by Matt is quite annoying for several reasons:

1. Once again, it ignores the fact that the US system rewards some patient populations and hurts some others just like every other system. For example, we spend much much more resources on the elderly (hm I wonder why they are so satisfied) in total than any other society and we see the results if one standardizes for health. They survive longer (at enormous cost) from bouts with cancer, get dialysis whenever they want (unlike Britain or France), get joint replacements (unlike Canada), etc. We also favor rare diseases (think ALS) and politically popular causes (AIDS, breast cancer), etc. over other possible uses of health dollars (prenatal care, etc.). Britain and France for example don't offer Herceptin. Try explaining that to breast cancer patients.

2. As follows from point 1, the groups that get screwed aren't going to be happy about our health care system. For example, the young, the middle-aged, the relatively well off, those concerned about universality, etc. are rationally not going to like our system but to pretend that it is in some absolute sense worse is highly misleading and deceptive. The same criticism applies to those who say it is "better".

3. Finally, Matt has a faulty syllogism in saying that France has a better system, a cheaper system and thus we should have a more french-like system. France does not (and nor does anyone else) have the same enormous fixed costs we have. Think the litigation system (and the defensive medicine/insane number of tests it inspires), the drug approval system (the FDA compared to everyone else), a vast underclass who constant replenish the uninsured numbers and a huge free rider problem (we aren't as good at enforcing anti-free rider norms as scandinavia for instance). In conclusion, there is no evidence about the crucial issue--whether a French system here is even possible, either politically or fiscally.

Posted by v | July 1, 2007 1:46 AM

Except...

Those nations are free riders on American Pharmaceutical research (no problem for the left though; the left hates those companies).

How many new drugs are being invented in Canada or France? Once you clone their systems, how many will be invented here? If you take the profit motive out of R&D, where do you expect the R&D to come from?

And here's a real mystery for Matt to ponder - next time you think the Feds are ideal for handling health care, head down to the DMV and stand in line for awhile. Then consider the fact that you just met the kind of people who will replace the insurance company bureaucrats.

If the faceless insurance company is bad, why will the faceless Feds be any better?

Posted by James Robertson | July 1, 2007 1:57 AM

Oh totally. Every government institution is like the DMV.

Posted by Dan | July 1, 2007 3:57 AM

So many Americans are like suckers who've been sold an expensive lemon by a crooked car salesman and are trying to justify themselves to their wives. All these tortuous, pathetic, half-assed excuses. Look: Do you really think that car salesman is your friend? You really think the US health insurance industry has your best interests at heart? Enough already. Ditch your gas-guzzling, expensive piece of crap Suburban that spends half its time in the shop, and buy a Toyota. More value for less money. End of rationalization.

I mean, not that I care. I moved out of the US in 1999, and have been enjoying better-quality European-based health insurance ever since (at about 1/4 of the price).

Posted by mattsteinglass | July 1, 2007 4:52 AM

James:A couple of real-world reasons.

Competition in the payment business (and that's really what we're talking about), is actually more inefficient than what any sort of monopoly would be. Each payment system has their own maze-like set of rules, regulations, forms that need to be followed, to the letter. This is a massive drag on the whole system. At least in Canada, you have one set of forms, (actually it's all computerized and automatic, even additional insurance.) and while it's still a bureaucracy, and sometimes bureaucracies suck...actually, they pretty much always do...they're a fact of life for any large organization. They're a necessary evil.

Hopefully, with a single-payer system, politicians will be put in place who actually care about good government, and not those looking to discredit it. (Hint. Any politician who's primary goal for being in government is to discredit/destroy it shouldn't be in office. Period.)

I wish that people would realize that the hypothetical DMV experience is something that's really done to you on purpose to aggravate you about the effectiveness of your government.

Posted by Karmakin | July 1, 2007 7:09 AM

Sullivan might be right on some issues, but let's not forget he's a diehard capitalist on this issue and would rather see dead children than a broke CEO.

Posted by Megro Please | July 1, 2007 7:49 AM

This seems to assume that there are no cultural differences between different countries which might contribute to health differences. And yet, we know this isn't true, as numerous studies have shown immigrants from healthier countries remaining healthier after they get here, while their children adopting American eating and exercise habits also end up with American health. As well, there are rather remarkable health differences between different cultural groups here, even when you control for health care.

So, the health care system might be contributing to these differences, but to assume that it's the deciding factor is a rather remarkable dismissal of the importance of regular exercise and a healthy diet.

The real question, then, is what you do about exercise and diet, without resorting to some remarkably totalitarian measures to FORCE people to eat right. I'd say a real start would be to address the way agricultural policy makes unhealthy food cheaper. And we might try making PE in K-12 education involve sweating again...

Posted by Brett Bellmore | July 1, 2007 8:01 AM

Its easy enough to see that each system of medical care has its drawbacks and ways that it might not work here. It is just as easy to see that of all the systems in the world ours is the least efficient, most costly and one of the least effective. Any system of any industrialized nation would be more efficient, less, costly and more effective. Most of the arguments against a national health service are bogus. For example:

A universal cradle-to-grave system would limit medical malpractice claims in that the tort damages would disaapear because all medical care would be paid for.

At least for a transition period, it would be perfectly acceptable to allow people who wish to pay for private health care to do so, so long as they have paid for the national system. Thus, the rich could continue to get what they get now as with school systems.

People don't want to be sick. They want to be healthy. A national medical system would help people stop smoking and put PE back in school.

We would train more doctors to care for the 40% of the population that is receiving no health care except in emergency rooms.

The real question is do we want a healthier society or a sicker one. Support for today's system is support for sicker.

Posted by Peter Driscoll | July 1, 2007 8:24 AM

Re: head down to the DMV and stand in line for awhile.

Last time I had to go to a DMV in person I was in and out in 15 minutes. Last time I needed to conduct business with them I was able to do it online. In case you haven't noticed most states have drastically reformed these offices. You might want to revert to the old post office analogy, though I can't say as I've ever had a miserable experience there either. Indeed, the worst customer service and longest waits have been at Walmart and various fast food restaurants. I suspect that's true for most people.

Posted by JonF | July 1, 2007 8:44 AM

People like to complain about the DMV (RMV in my state.)

I don't know about other states, but my state has a very well-organized RMV. You can get a lot of the services online; they use an electronic queueing system in the offices so make whatever wait there is fairer; you can get current waiting times for each office on line (so you can decide when/where to go).

I would say their system compares favorably to that of hospitals I have visited. I've certainly waited longer for doctors where we had scheduled appointments than I've ever waited at the RMV.

Posted by matt wilbert | July 1, 2007 8:44 AM

How many new drugs are being invented in Canada or France?

Dear silly people using the pharmaceutical argument to defend our health care system:

Read this post. On this particular point, note:

The #4 company, Sanofi-Aventis, is French.

As for the DMV argument, I could well say: "next time you think private companies are ideal for handling health care, head down to U-Haul and have them explain why the truck you reserved two months ago isn't available the day you moved." Or I could just tell my experience of having HMO bureaucrats trying to deny me walk-in care for a sprained thumb, and then referring me to a specialist who was out of town for the entire time that I was supposed to be receiving care.

Posted by Matt Weiner | July 1, 2007 8:46 AM

As a bonus, I'll link to this post by Mark A.R. Kleiman, arguing that "Where are drugs made?" is the wrong question, and that moving to universal healthcare would call for some subsidies for drug research. But it doesn't seem necessary to keep our awful system in place as an indirect subsidy to drug manufacturers; better to subsidize them directly.

Posted by Matt Weiner | July 1, 2007 8:51 AM

The problem with that is that, under the current system, to a large extent we get the drugs the public actually wants. Under a system of subsidized research, we'd get the drugs the government thinks we OUGHT to want.

Whether or not you think that's an improvement depends, obvously, on your view of government. I'm flatly amazed at how little 6 years of Republican control has changed Democrats view of government... It's like you consider Republican control of government a bizzare aberation, rather than an occasional inevitablity.

Posted by Brett Bellmore | July 1, 2007 9:07 AM

What we get now is drugs that the pharmaceutical companies think they can sell profitably. Because of the peculiar economics of the drug business, I see no reason to believe those match up well with the drugs the public "actually wants".

And we already have a system of subsidized research. We spend a quite a lot of money on the NIH and NSF, I think, and a large percentage of our drugs come out of that research.

Posted by matt wilbert | July 1, 2007 9:45 AM

My recent experience with the local DMV is also excellent. If you want an analogy to a government service, think about fire departments. We could get along fine without them, just use private insurance, for-profit fire brigades or voluntary associations.This is what happened in the early years of the republic. Somewhere along the way, we realized that it was better for all of us if fires were put out (with the added advantage that the government controlled patronage jobs). It arose with urbanization. So it is with public health. Its simply better to have a healthy population via government monopoly than to attempt to regulate competing duplicative services. The analogy can be further expanded, but it is a better and more useful analogy than the DMV.

As to drug companies, you must be kidding! The government grants them monopolies called patents and the companies scream about regulation. We have TB, AIDs, MR staph infections and the drug companies take no responsibility for helping to end these scourges. Instead, they create different colored dick stiffeners and psychosis-inducing sleep aids. Lets just leave the drug cartel out of discussions concerning improving health care.

Posted by Peter Driscoll | July 1, 2007 9:51 AM

If Michael Moore is so fast and loose with the facts, as many claim, when can we expect the sites debunking "Sicko" to appear?

Posted by Brian | July 1, 2007 10:14 AM

Just to follow up on what Peter said, it's well known that treatments are more profitable than cures. So drug companies focus on long-term treatments rather than short-term cures. Obviously this is quite a big market failure, and where directly controlling (I like the idea of a large prize fund for discovering needed cures).

This is a good example of how sometimmes the free market doesn't come up with the best results. (Although with patent monopolies, it could hardly be called a free market)

Posted by Karmakin | July 1, 2007 10:24 AM

Those nations are free riders on American Pharmaceutical research (no problem for the left though; the left hates those companies).

This is the point Sullivan keeps harping on. I'm somewhat sympathatic to the position he has carved out, since the HIV drugs invented by big pharma clearly saved his life. I'd probably make the same argument if I were in his shoes. But that doesn't mean he's right.

Drug costs are only one part of the overall healthcare puzzle. Indeed, redesigning the US health care system is going to require a variety of compromises and it's not too tough to envision methods of preserving pharmaceutical R&D budgets while reconfiguring other sections of the system. You can subsidize big pharma R&D directly, the same way the Bush Administration has subsidized oil companies for "oil exploration." You can pour more money into the NIH, which funds a majority of the medical research in this country anyway. You can figure out ways to fund the small start-ups that big pharma buys up when the start-up creates a drug with potential. You can incentivize venture capitalists who invest in pharmaceutical start-ups, to cover any increased risks created by the new system.

My point is simply this: redesigning the health care system is a massive undertaking that presents incredible challenges. Maintaining funding for pharmaceutical R&D in the midst of such a redesign is a much, much smaller problem. Anyone who argues that we shouldn't redesign the US healthcare system because it may reduce big pharma's R&D budgets either (a.) doesn't understand the problem or (b.) is using big pharma as an excuse for not doing anything.

Besides, it's not like the current drug production system is perfect. We live in one of the most overmedicated societies on earth, where individuals are bombarded with advertising about medicines that promises to turn their lives into places where the sky is always sunny and everyone is always happy. The same system that is producing all these ads is producing fewer and fewer revolutionary drugs. A change just might do us good.

Posted by owenz | July 1, 2007 10:37 AM

If there were any real problem with medical malpractice awards, that system would be reformed to resemble workman's comp so fast it would make your head swim.

Back in the day, workers injured on the job got the same deal a patient injured by malpractice gets today- "So sue me already!" That worked for big industry as long as the workers couldn't really sue, just like it works for doctors and hospitals today. If you've ever experienced medical malpractice, you'll know what I'm talking about.

When workers got the ability to win suits and be compensated for their on-the-job injuries, the system was changed. Now industry pays into a pool, safety conditions are regulated, and the worker can no longer sue, but does receive compensation at fairly predictable rates if they are injured on the job.

When I started working in the industry, hospitals routinely provided free care for patients who had been injured by the hospital or doctor. Unfortunately, this fast and loose bookkeeping was associated with other evils, like charging the patients for the lunches the doctors ate free in the 'doctor's dining room' (to which no women were admitted, even if they were doctors). Good times, good times.

When and if patients ever get the real ability to seek compensation, the doctors and hospitals will demand a system like workman's comp- and undoubtedly get it.

Posted by serial catowner | July 1, 2007 11:19 AM

Matt seems to take the same tact as Moore for promoting his vision of healthcare. Only look at one side of the issue. Thats fine if you want to be a propogandist, but for the majority of thinking americans who want to understand the real pros and cons all the different alternatives, it's ultimately unpersuasive.

Posted by Dave | July 1, 2007 11:25 AM

Incidentally, the post by "v" was irritating for a specific reason.

"v" says Britain and France don't offer Herceptin- "Try explaining that to breast cancer patients."

It would be the same explanation that is offered at any given time to 45 million Americans about any drug or treatment- you can't pay so we won't provide.

Yes, according to "v", when patients in Britain or France are denied access to one drug, that proves those systems don't work.

But when 45 million Americans are denied access to any drug or treatment, well, according to "v", that's a good thing.

Survival of the fittest, or something to that effect, no doubt. IOW, abandon all hope, ye who enter here.

Posted by serial catowner | July 1, 2007 12:14 PM

to serial catowner:

1. Reread my post. I think it is clear that I was making the point that all systems involve tradeoffs NOT that some systems don't work, etc. and that these tradeoffs are by no means going to be popular when they are explicitly laid out.

2. Uninsured ppl actually do not differ in their treatment results from any other group in the population. The main issue is their cost because they are treated in emergency rooms for free by law (look up EMTALA). Thinking of them dying in a Dickensian world is just ignorant oversentimentality.

3. There's a case to be made for your last statement but its not me making it. Try sticking to my arguments and not the ones you make up in your head.

Posted by v | July 1, 2007 1:35 PM

Under a system of subsidized research, we'd get the drugs the government thinks we OUGHT to want.

Except that subsidised research already exists, and it doesn't really work that way. Subsidy works best in primary research -- university labs, national foundations -- where the aim is to create good research science and expand fields of knowledge.

We live in one of the most overmedicated societies on earth, where individuals are bombarded with advertising about medicines that promises to turn their lives into places where the sky is always sunny and everyone is always happy.

The US has a really strange 'health culture' if you're used to a universal system. The combination of DTC advertising and high costs means there's a culture of self-diagnosis and self-medication, along with a crypto-libertarian belief in a Giant Medical Conspiracy which means people will buy unregulated snake oil pills as supplements because of the presumption that cheap remedies are being kept secret from the public.

On the one hand, it's a good thing for patients to read up on their conditions. On the other hand, I'm not convinced that people should feel compelled to spend hours on the web poring through clinical journal articles before they take the plunge and see a doctor, in the knowledge that they might end up with an insurance-denying condition on their records.

Only look at one side of the issue. Thats fine if you want to be a propogandist

As Moore notes, it's not as if drug companies and health insurers are denied a platform.

Anyway, what's refreshing about Sicko is its focus on outcomes. Is there the collective will for all Americans to have access to healthcare, at a reasonable price, at a point where it's most efficacious? Moore's throwing out an appeal to the better angels. You don't have to agree with that sense of the national character. If not, then fine: but there should be a degree of honesty in describing the US system as great for the rich, shit for the working poor, and a crapshoot for the middle-class.

One final point: if you're going to run with the 'universal care harms pharma R&D' argument, then how is it different from 'preventative care, screening and vaccination harms pharma R&D'? Aren't colonoscopies by definition impacting incentives to develop colon cancer treatments?

Posted by pseudonymous in nc | July 1, 2007 1:35 PM

I don't think I've ever found a series of comments to be so terrifying. Dave seems to be the only one who isn't spouting hyperbole.

Matt, the WHO report isn't the best supporting evidence. It's main criticism of the US is that our poorer populations spend a greater percentage of their income on healthcare than the rich. This "indicator" seems tailor-made for nationalized systems, but doesn't really get to the heart of the problem. I suppose if you think we should subsidize food for the poor because they spend a larger percentage of their income on food than the rich, the WHO report works well. My own feeling is that satisfaction is the best indicator, and the US is number 1.

Also, can someone explain how subsidizing pharma companies would encourage them to spend more on research and development?

Posted by Nick | July 1, 2007 2:33 PM

And here's a real mystery for Matt to ponder - next time you think the Feds are ideal for handling health care, head down to the DMV and stand in line for awhile.

OMG! Bureaucrats! Teh socialism! Our facts and figures are useless against the impenetrable forcefield of libertarian tautology!

Next time you think the private sector is ideal for handling health care, try getting your insurance company to pay for a strep throat culture over a holiday weekend when your primary care provider is vacationing in Aruba. Then lose your job and get pneumonia.

Or, if you need additional anecdotes about the natural efficiency of free enterprise, call Comcast and ask them to resolve intermittent problems with your cable modem.

Posted by LaFollette Progressive | July 1, 2007 2:58 PM

What we get now are the best drug ads that money can buy. And LOTS of them.

Posted by Jeffrey Davis | July 1, 2007 2:59 PM

France and Canada both have two difference systems of health care delivery both of which are cheaper than the US system and both of which are more effective.

Here we go again. France and Canada certainly spend less money on health care than the U.S. does, in both absolute per capita spending, and spending as a fraction of GDP. But no, their health care systems are not "more effective." Or, at least, there's no serious empirical basis for claiming that they are more effective.

Posted by Mixner | July 1, 2007 3:27 PM

Thank you Nick. I was just about to point out the logical fallacy of using the WHO rankings myself.

Posted by David Masten | July 1, 2007 3:49 PM

The rankings of different nation's health care systems in the WHO report are a joke. For instance, the "performance on level of health" ranking is based on a single measure of health: disability-adjusted life expectancy. But the influence of a health care system on life expectancy is very small. It is swamped by other factors such as behavioral patterns and environmental influences. The WHO report has been strongly criticized in the academic public health community for these methodological problems.

Posted by Mixner | July 1, 2007 4:03 PM

The mystery seems to be why we can't have a discussion about whether we want a better health care system than the one we have without descending into obscure or irrelevant questions such as "is French health care better than ours" or "can't we do something about the drug companies?" The fact is that our system, on average, as near as anyone can tell, is the least efficient, highest cost in the world. It is also not the most effective and, except for some odd exceptions such as Saudi Arabia, the least equal. We can do better. One way to do better is to make health care more available. The way to make it more available is to provide more services, and here is the part everyone hates to hear, for the same cost. This is done by cutting government support for drug companies, eliminating the overhead costs at insurance and HMO/PPO operations to the level of CMS and foreign health care systems. This can be done, but not with the incorporation of profit in the scheme. Thus, the question is what is more important to the United States, a healthier population, or a profit for providers, because that is the question. Certainly some, such as Mixner will argue that it hasn't been proved that a health care system without a profit will be an improvement. Well, not to his satisfaction perhaps, but its close enough to certain, at least in my judgment to give something else a whirl.

Posted by Peter Driscoll | July 1, 2007 5:28 PM

"The question is what is more important to the United States, a healthier population, or a profit for providers."
-Peter Driscoll

No, the question is if we can increase the level of services provided to the poorer segments of our population without sacrificing the ability of those who can pay to obtain treatment. Or if we can't, whether that tradeoff is a good one. In fact it gets even more complicated once you take into account incentives for innovation and whether 50 years from now the poor might be better off if we keep a partial-private market. Breaking it down into a good vs. greedy argument gets us nowhere.

I think that the medical progress over the past 20 years is reason to keep doing what we are doing. If it means spending an ever-increasing percentage of GDP on medical care, so be it, MRIs aren't cheap. A further worry is that cost containment will dissuade many of our brightest students from becoming doctors. At the very least can we agree that doctors should be able to charge what they want for their services?

Posted by Nick | July 1, 2007 6:29 PM

For the record, there is a difference between getting treated at the ER and getting the drugs you need or the care you need.

Numerous studies have shown that many older Americans do not take the drugs their doctor prescribed as their doctor ordered because they can't afford to. This is a well-known problem in what we call "patient compliance". I personally cannot afford to take the drugs my doctor would like to have me taking because I can't afford them and we are not talking about fancy drugs here that might not be necessary, we are talking about the basic drugs needed to treat the problem.

And by now it should be no secret that that care at the ER, if you can't afford to pay, will be just enough to get you out the door. One night i was taking a break by the ER of a private hospital I was working for, and a guy came in with a broken arm. They called a taxi and sent him to the county hospital.

Working for the county hospital, one night a little after midnight I saw a guy discharged with a large wound, packed and dressed, and instructions to return for dressing changes. He was homeless, so they gave him bus fare to get to the bridge he was going to sleep under. I am not making this up.

It seems some people have a hard time believing what things are like in America. If it makes you that uncomfortable, you ought to do something about it.

Posted by serial catowner | July 1, 2007 6:30 PM

A couple of points about foreign drug companies:

1) Large foreign drug companies often have significant operations here.

2) Even small foreign drug companies make a lot of money selling drugs here. For example, I own stock in two small-cap Canadian drug companies, Aspreva Pharmaceuticals and Axcan Pharma. Both, I'm sure, get most of their revenue from drug sales in the U.S.

In short, even drug companies headquartered in countries with socialized medicine profit from America's partially-free market health care system. What effect would our move toward fully-socialized medicine have on their incentives and resources for drug development?

Posted by Fred | July 1, 2007 6:34 PM

What Nick is missing is that hospital beds and scanners are already paid for by the existing patients whether they are used to capacity or not.

On a number of occasions I have made a rough calculation of what the nursing cost was per patient, and it never came out to be more than a quarter of what the hospital was charging for a hospital day. Almost all of the cost is overhead for the whole plant, and if there are fewer patients they simply pay more than they should. This is why there are regional authorities almost everywhere trying to prevent overbuilding of hospital beds, usually with almost no success.

The same is true for a scanner- the actual cost of a scan is trivial compared with the capital cost of the machine. Whether there are few patients or many, the overall gross cost of the whole setup remains about the same.

Ironically, the refusal of American medicine to treat everyone, thus increasing the base for amortization and evening out the peaks and troughs of demand, results in good care not being available, even to the rich, outside major metro areas. What we're doing now is expensive, but does not result in better care.

Posted by serial catowner | July 1, 2007 6:41 PM

serial catowner:
I see how nationalized health care would level the standard of care between urban and rural areas, but it could only do this by increasing health expenditures (perhaps you believe savings in other areas would outweigh this increased cost). As for excess hospital beds, I don't see how a free market system encourages this. Wouldn't hospitals profit by charging patients the same rates and having fewer beds? It seems like this phenomenon must be caused by something other than free markets. One alternative explanation is gov't regulation, such as antitrust laws, see e.g. FTC v. Tenet Health Care Corp.

Posted by Nick | July 1, 2007 7:15 PM

I should have said that another way to level the standard of care between rural and urban areas would be to decrease the level of care in urban areas.

Posted by Nick | July 1, 2007 7:16 PM

Nick:
I don't think its a good versus greedy argument.

I agree with Nick that one "question is if we can increase the level of services provided to the poorer segments of our population without sacrificing the ability of those who can pay to obtain treatment." The answer, I believe, based on the experience in other nations, is yes, we can provide more services for the same money and thus improve the public health. Among other things, that will entail ending the profit incentive as a means to acheive expanded service. So, why does it resonate with people when Michael Moore points out that their health care sucks? Its because they know the truth. Their health care sucks. Moore makes a target of the insurance companies. Its kind of a cheap shot, because their motives (greed e.g) are not really relevant and he skirts the real question which is: do you want to try a healthcare system without profit to try to make it available to everyone like we do with schools and police and fire departments, or do you want to keep going like this? The well off don't see the need, but they are becoming a smaller and smaller part of the population. Further, As the medicare population grows, there will be more, not fewer advocates for universal coverage. I submit that its not about greed, but the nature of the social contract among us.

Posted by Peter Driscoll | July 1, 2007 8:19 PM

These endless complaints about the "profit motive" and the "profit incentive" are really bizarre. Our whole economy is built around the profit motive. Virtually every major kind of product and service we get, from housing to food to cars to employment, comes from the profit motive. "The business of America is business," remember? Why should health care be different?

The fact is, our health care delivery system is almost entirely driven by the "profit motive." Hospitals and physician practices and drug companies and MRI machine manufacturers and are in business to make a profit. Are you proposing to nationalize the health care delivery industry, to eliminate the dreaded profit motive from that too?

Even looking just at the funding side of health care, for-profit private health insurers provide a significant fraction of total health care funding in many OECD nations. France has the third-highest share of health care funded by private, for-profit insurance among all OECD nations, behind only the U.S. and the Netherlands. And in countries without significant private health insurance, out-of-pocket costs to patients tend to be larger: 24% of total health care spending in Spain, 23% in Italy, 52% in Mexico.

Posted by Mixner | July 1, 2007 9:17 PM

We need to force the AMA to loosen restrictions on admitting qualified foreign doctors into our system.

Perhaps we can also dramatically increase the number of Physician Assistants, who can lessen the demand for Doctors today without significantly impacting care (do we really need Doctors to treat rashes). The AMA is currently having a fit with Physician Assistants though.

Bottom line: The AMA is a greedy organization.

Posted by thehova | July 1, 2007 10:53 PM

V: Yes, France and the UK may deny some drugs we offer here; that cuts both ways, though.

Mixner: The way private insurance is headed here, more and more ppl will approach the Spanish level of personal care funding soon.

SerialCatowner has good points which need follow-up. Hospitals have become the D.R. Horton, Pultes, etc. of the health care world with a "hospital facilities bubble." I include not just actual buildings, but high-cost, high-tech equipment, etc.
Part of a rational national healthcare system would make hospitals cartelize their use and purchase of a lot of this equipment.

As for those ppl who think the government will wreck medicine with "socialism," take a look at how well the VA operates. I'd be more than happy to see a national healthcare system that good.

Posted by SocraticGadfly | July 1, 2007 10:58 PM

Moore's main point in Sicko was about people who DO have health insurance, get sick and still can't get treatment. It really isn't helpful to have a health care system that doesn't treat its customers.

Posted by D. | July 1, 2007 11:23 PM

As for those ppl who think the government will wreck medicine with "socialism," take a look at how well the VA operates.

You have much experience with the VA? I don't think it's failings have anything to do with "socialism", but dear god, don't look at the VA as a model of universal health care.

Posted by Ed Marshall | July 1, 2007 11:38 PM

am I the only one on this board concerned with doctor's near monopoly over our health care system?

this type of article concerns me:

http://www.chicagotribune.com/news/nationworld/chi-0627edit2jun27,1,7303407.story?coll=chi-newsnationworld-hed

Posted by thehova | July 2, 2007 12:58 AM

Jane Galt puts Yglesias' weak analysis to bed:

http://www.janegalt.net/archives/009873.html

Posted by John Seymour | July 2, 2007 2:37 AM

Mixner,

thanks for the link to WHO and Private health insurance.

France comes third, and I confess Iwas surprised, I expected Switzerland, Singapore and Germany ahead of France.
But after reading again:
-Singapore is not in the OECD
-germany is very very close
-Switzerland is a borderline case:
"For Switzerland, data on PHI refer only to voluntary private health insurance coverage. Mandatory health insurance covering the entire population is reported in OECD Health Data as public coverage, although it is a border line case."

What you don´t comment is the following: it seems thee is a pattern there, and that the US don´t follow it: they have to be excluded more often than not for the regression analysis.

Clearly the US, Switzerland and Mexico are outliers for the public expenditure rate in health financing.
Funny: The US and Switzerland are 2 of the 3 countries with the less public financing and the 2 countries where Private Insurance are managing the most money, and the 2 are spending - by far!-the most in absolute term (% of GDP).
So much for the efficiency of private companies in the health financing "market".

I don´t know much about Mexico, maybe you could tell me it is the better model you envision?

Posted by Singaporedoubter | July 2, 2007 3:21 AM

I am truly amazed and amused by these dogged, dead-end supporters of our abysmal health care system. You must really be driven by some kind of over-powering pathology. Let's take a real bottom-line, basic differential that might even seep through the skulls of you dense, labotomized jingoists. Even comfortable middle-class--and insured--Americans can go completely bankrupt and destitute if they fall seriously ill, or have a catastrophic injury that results in 10's or 100's of thousands of dollars of medicals bills and the insurance company refuses coverage or drops the client for whatever pathetic reason, which happens with regularity in our country. There is no other advanced Western country where this is the case. Plain and simple distinction here, okay. Imagine I am s-p-e-a-k-i-n-g v-e-r-y s-l-o-w-l-y so the ramifications of this basic fact can bore its way through the years of right-wing indoctrination.

And by the way, do see the Michael Moore film, it's excellent and he takes his dark-humor thing to a new level. He's really mastered the whole aww-shucks ask the stupid, obvious question and wait for the answer. He's made it into an art form. Yes, a good portion of the exposition is anecdotal, but he embeds it in a convincing statistical, comparative framework. Oh, but I forgot, we do everything better than everyone else, so we couldn't possibly learn anything from the rest of the Western world, right?

Posted by Warren | July 2, 2007 4:01 AM

Warren-

I think you reframed Matt's quetion perfectly. Our healthcare system is rotten. Others are better and those arguing against change have only nit picking, techno-babble, and insipid reasoning to offer. Moore asks questions that we want to ask our "insurers" except we feel that our service will get worse if we don't "cooperate." After all, the consumer can go nowhere once they're sick -- pre-exisiting condition -- what a free market concept! Hostage and kidnapper at point of sale! The Stockholm syndrome as a free market principle leading to public health! Anyway, time is on our side. As Herb Stein noted: If something can't go on forever, it will probably stop.

Posted by Peter Driscoll | July 2, 2007 6:18 AM

Posted by Warren | July 2, 2007 4:01 AM :"I am truly amazed and amused by these dogged, dead-end supporters of our abysmal health care system. You must really be driven by some kind of over-powering pathology. Let's take a real bottom-line, basic differential that might even seep through the skulls of you dense, labotomized jingoists. Even comfortable middle-class--and insured--Americans can go completely bankrupt and destitute if they fall seriously ill, or have a catastrophic injury that results in 10's or 100's of thousands of dollars of medicals bills and the insurance company refuses coverage or drops the client for whatever pathetic reason, which happens with regularity in our country. There is no other advanced Western country where this is the case. Plain and simple distinction here, okay. Imagine I am s-p-e-a-k-i-n-g v-e-r-y s-l-o-w-l-y so the ramifications of this basic fact can bore its way through the years of right-wing indoctrination."

OK. I get the picture. People can be faced with big bills to pay. But consider the other side of the story. At least in America if you can pay, even at the cost of bankruptcy, you can get the treatment you want. How does it work elsewhere? Well that does not follow. Health care has to be rationed. How is it rationed? Well we have all discussed waiting queues - Tony Blair wanted to get the average waiting queue down to 18 weeks after seeing a GP. About half of all health care authorities manage that. The rest do not. So no one much cares about this I guess - although try waiting in pain for more than 18 weeks. How else might it be rationed? Well in the good old days the NHS had an informal policy of rationing donor organs - no one over 40 was given any unless there was no one else who wanted one. This is a fairly sensible decision as young people are better bets for tax-hungry governments. Anyone care about the old being denied health care? This does have more serious implications as it is also likely that across Europe people were denied health care if they were of the wrong ethnic origin. This is harder to prove because there does not seem to be a paper trail, but it is worth noting that until the mid-1970s Sweden had a policy of sterilizing the mentally-ill or racially-unfit. Something like 64,000 people were sterilized. Now this is not mandatory in a state-run system, but it is a hell of lot easier to do and more or less implicit in the nature of the system. Even if you ignore these, Britain has NICE. It decides what should be funded. Theoretically they fund health care if it is cost effective. Increasingly governments bow to lobbies so that the loudest and angriest get the health care they demand and the rest do not. This is an evil in and of itself. When NICE does work properly, it behaves reasonably - they decided, for instance, that some expensive forms of eye operation were too expensive so they will only pay for one eye to be done. Think about that. There is one other decision that really gets me - these decisions are arbitrary and utterly irrational from what I can see. A middle ranking bureaucrat decides that a hospital ought to be shut and it is shut. There is no appeal and explanation. When the market does this it is bad enough but I can accept the logic of the market. But a bureaucratic fiat is appalling.

Posted by Warren | July 2, 2007 4:01 AM:"Oh, but I forgot, we do everything better than everyone else, so we couldn't possibly learn anything from the rest of the Western world, right?"

Everyone knows the American system has problems. Those problems ought to be fixed without destroying the health care system which *does* drive most of the world's health care innovations. So be careful in what you learn from overseas.

Posted by HeiGou | July 2, 2007 6:40 AM

From the Commonwealth Fund:

"Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to two earlier editions—includes data from surveys of patients, as well as information from primary care physicians about their medical practices and views of their countries' health systems. Compared with five other nations—Australia, Canada, Germany, New Zealand, the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives. "
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

Posted by Peter H | July 2, 2007 7:38 AM

Re: Well in the good old days the NHS had an informal policy of rationing donor organs - no one over 40 was given any unless there was no one else who wanted one.

40 seems a bit young, but there is a cut-off point of age where a patient's chances of a successful outcome become unacceptably small. Even the US recognizes this and under our system too people over a certain age do not get certain procedures, no matter whether they can pay cash or not. And that is a medically sound decision. Got a problem with it? Triage is a fact of life in medicine everywhere and I see no reason to drum up boogeyman fears of it.

Re: . Anyone care about the old being denied health care?

Since life expectancies in Western Europe are at least as high as ours, if not slightly higher, this seems to be a strawman fear. If the elderly were being shuffled off to the graveyard in great numbers we'd see it reflected in the statistics.

Re: but it is worth noting that until the mid-1970s Sweden had a policy of sterilizing the mentally-ill or racially-unfit.

Such things were done in the US too. And worse. Ever heard of the Tuskegee Airmen?

Posted by JonF | July 2, 2007 8:18 AM

Truly amazing: My point about cultural differences in diet and exercise having a profound effect on a country's health quite independent of the health care system a country might have, has vanished into the void, completely ignored.

Apparently nobody wants to confront evidence that Americans are unhealthy because we eat unhealthy diets, and don't exercise enough. I guess because this doesn't immediately suggest a government program is the solution... At least, not a government program which has a snowball's chance in hell of being accepted by the public.

Posted by Brett Bellmore | July 2, 2007 8:27 AM

Such things were done in the US too. And worse. Ever heard of the Tuskegee Airmen?

Yes, they were WW2 fighter-escort pilots. I think you're thinking of the Tuskegee Experiments. :-)

Posted by ajay | July 2, 2007 8:55 AM

Posted by JonF | July 2, 2007 8:18 AM
:"40 seems a bit young, but there is a cut-off point of age where a patient's chances of a successful outcome become unacceptably small."

Sure but 1. is it closer to 70 than 40 and 2. who do you want making that decision: your HMO which you can change or your government which will not even tell you? The chances of Blacks getting organs are low enough. You don't think there is a risk that non-medical factors might go into some decisions?

Posted by JonF | July 2, 2007 8:18 AM:"Triage is a fact of life in medicine everywhere and I see no reason to drum up boogeyman fears of it."

Triage is a fact of life. And doctors who do so on a non-medical basis are likely to be caught. In America. They are less likely to be so elsewhere *especially* when such decisions are made by, to all intents and purposes, unaccountable bureaucrats.

Posted by JonF | July 2, 2007 8:18 AM:"Since life expectancies in Western Europe are at least as high as ours, if not slightly higher, this seems to be a strawman fear. If the elderly were being shuffled off to the graveyard in great numbers we'd see it reflected in the statistics."

Depends on what else is happening. You assume that medical treatment has much of an impact on life expectancies - China and Cuba would suggest that high end medicine is less important than you might think. Also the American population is amazingly unhealthy. Maybe the Europeans are just not denying enough treatment to enough old people. The impact in the statistics is not that important so much as what the impact on lives is.

Posted by JonF | July 2, 2007 8:18 AM:"Such things were done in the US too. And worse. Ever heard of the Tuskegee Airmen?"

You do not mean the Tuskegee Airmen but the Tuskegee Study of Untreated Syphilis in the Negro Male. The Airmen fought in WW2 with distinction.

Such things were not national policy and they were not done as national policy for 40 years. It is also worth pointing out that although Tuskegee University was a private institution, the driver of the study was the Federal government's Public Health Service. Nor do I see the sense in comparing a passive act (the refusal to treat 399 men which only became a serious ethical problem after 1945) with an active act (the sterilization of 64,000) even if we ignore the two orders of magnitude between the two experiments in populations an order of magnitude smaller.

But of course as we all know, America is always wrong and is the source of all evil in the world.

Posted by HeiGou | July 2, 2007 8:57 AM

Brett -- The reason your point about cultural differences dropped into the void is that the type of health care delivery system chosen is not relevant to changing what you describe as "lifestyle choices." Whether its insurance companies, the government, or your private doctor, you will eat, drink, smoke, and exercise pretty much the same way you always have. Now, if you want to end these "lifestyle choices" through limits on promoting bad behavior or encouraging good behavior in advertising, you may make some progress, but will have a real fight on your hands.

Posted by Peter Driscoll | July 2, 2007 9:08 AM

Posted by Peter Driscoll | July 2, 2007 9:08 AM:"The reason your point about cultural differences dropped into the void is that the type of health care delivery system chosen is not relevant to changing what you describe as "lifestyle choices." Whether its insurance companies, the government, or your private doctor, you will eat, drink, smoke, and exercise pretty much the same way you always have. Now, if you want to end these "lifestyle choices" through limits on promoting bad behavior or encouraging good behavior in advertising, you may make some progress, but will have a real fight on your hands."

I am not entirely sure that is true. The extreme case is Cuba where the type of government shapes the type of health care and the type of economy which in turn changes a lot of lifestyle choices - everyone has to ride bicycles and they jail anyone with HIV which I would think tends to crimp their choices.

Even if you ignore that extreme, where insurance companies can charge smokers higher rates, they do. That influences life style choices. The British NHS and the BMA has been lobbying for a while now to deny health care to smokers and the obese. That changes people's lifestyles too. The BMA et al can because they are not operating in a customer-driven market.

Finally you only have to look at HIV prevention, needle exchanges for instance, to see that choices by the government and health care providers can make a big difference indeed.

Posted by HeiGou | July 2, 2007 9:13 AM

Truly amazing: My point about cultural differences in diet and exercise having a profound effect on a country's health quite independent of the health care system a country might have, has vanished into the void, completely ignored.

Apparently nobody wants to confront evidence that Americans are unhealthy because we eat unhealthy diets, and don't exercise enough.

Brett,

There was a study in the Journal of American Medical Association that compared the health of white men aged 55 to 64 in England to the United States. In each socioeconomic group, English white males were found to be healthier than American white males. Behavioral factors (smoking, overweight, obesity, and alcohol) accounted for very little of the differences in health care outcomes. That's not to say that the different health care outcomes explain the divergences either, but it can't be attributed to Americans being more fat:

http://jama.ama-assn.org/cgi/content/short/295/17/2037

Posted by Peter H | July 2, 2007 9:44 AM

HeiGou--

I may have been painting with too broad a brush, but the Cuban example doesn't support the position that the type of health care system influences personal behavior all that much. Jail does, but I don't think that's been suggested in this thread yet. Charging more for smoker's health insurance just makes the enterprise cost more. It doesn't stop smoking or improve public health. Taxation seems to work, but that is not a health care system choice. HIV prevention of the type you describe (and through condom and education dissemination) is done under all types of health care systems although it is much more easily accomplished by direct government intervention than by a health system.

Cultural behavior differences may make comparisons more difficult among different health care systems, but it will not affect outcomes in any system all that much. In other words, the type of system you use will not much affect how you behave, at least in the short run. The mystery is still why, when we could have a better system, do we have this one?

Posted by Peter Driscoll | July 2, 2007 10:10 AM

I'm not sure what the point of this is:
> Well in the good old days the NHS had an informal policy of rationing donor organs - no one over 40 was given any unless there was no one else who wanted one. This is a fairly sensible decision as young people are better bets for tax-hungry governments.

Are you saying that the NHS was overflowing with donor organs but allowed organs to rot in the garbage (or perhaps they sold them for a profit to Americans?) because they didn't have people under 40 to put them in? When demand is higher than supply, organs shouldn't go to who can pay the most, but to who is most likely to use it most. It's an equation that seeks to maximize the length of time all donor organs are used, since that is how to minimize the waste of the donor organs. Any other method is wasteful, pure and simple.

The American system wouldn't insure any elderly people if it wasn't for Medicare. Elderly people have a pre-existing condition (being old) and would be terrible investments. It's pretty incredible that you would use the one area where the US has a national health care system to suggest that it doesn't need a national system for everyone.

The fact that you just accept the "market logic" of the bureaucracy that actively works against you just takes my breath away. It doesn't bother you that many times the result is at best the same or worse as long as it's some company whose sole purpose is to make money by minimizing the amount of money paid for your health, but the idea of a government bureaucrat makes you wet yourself in fear. Can't we just agree that both are unpleasant, but the fact that the government bureaucrat will not be getting bonuses to deny coverage makes that bureaucrat likely to be more fair to you?

Posted by ScottH | July 2, 2007 11:26 AM

Serial Catowner,

I want to push back on your comment about medical malpractice. My understanding is that many doctors (particularly surgeons) pay 100K-200K per year in malpractice insurance. I can't imagine this doesn't motivate them to try and fix the problem, they just haven't been successful. What about this picture do you disagree with? My suspicion is that they aren't motivated b/c they know they just pass those costs on to patients. But this is bad for us b/c malpractice is costing us a ton, but not really helping us out. The problem with torts is that they're irrational and unpredictable. So a few people get stupidly huge jury awards, most legitimate cases get nothing and lawyers suck up loads of legal fees. In absolute terms I'm not sure how it compares to the loss associated with private insurance (incurred both in the doctor's office and in management at the insurance company) but it does seem to impose losses on our system that are avoided in Europe. Unfortunately for me, my favorite candidate is a former medical malpractice attorney, so I don't see this problem as likely to be fixed under his administration.

Posted by mpowell | July 2, 2007 12:11 PM

Posted by Peter Driscoll | July 2, 2007 10:10 AM:"he Cuban example doesn't support the position that the type of health care system influences personal behavior all that much."

Apparently having no oil means a lot more bike riding which has had a measurable impact on heart disease in Cuba. But that is only anecdote I've heard.

Posted by Peter Driscoll | July 2, 2007 10:10 AM:"Charging more for smoker's health insurance just makes the enterprise cost more. It doesn't stop smoking or improve public health."

It makes insurance more expensive and is likely to have an impact on rates of smoking. Evidence shouldn't be hard to find.

Posted by Peter Driscoll | July 2, 2007 10:10 AM:"HIV prevention of the type you describe (and through condom and education dissemination) is done under all types of health care systems although it is much more easily accomplished by direct government intervention than by a health system."

Where private systems fall down in prevention. State run systems do that very well (and most of China's success is down to such programs). I don't really see how private health systems could run a proper HIV prevention program.

Posted by Peter Driscoll | July 2, 2007 10:10 AM:"In other words, the type of system you use will not much affect how you behave, at least in the short run."

Although in the long run it is likely to have a real impact.

Posted by Peter Driscoll | July 2, 2007 10:10 AM:"The mystery is still why, when we could have a better system, do we have this one?"

Could is nothing like will. Anyone can devise a theoretical system that is better than the present one. This is why these reforms usually get made - we are all agreed on the theoretical possibility of improvement. What America would get if it junked the present system is another matter. I like Singapore's system myself.

Posted by ScottH | July 2, 2007 11:26 AM:"Are you saying that the NHS was overflowing with donor organs but allowed organs to rot in the garbage (or perhaps they sold them for a profit to Americans?) because they didn't have people under 40 to put them in?"

No I am saying that they did not necessarily look for the best match or operate and open and fair system, but simply had a blanket ban on people over 40 getting them. Organs are not so common that someone can't be found for them after all.

Posted by ScottH | July 2, 2007 11:26 AM:"The American system wouldn't insure any elderly people if it wasn't for Medicare. Elderly people have a pre-existing condition (being old) and would be terrible investments. It's pretty incredible that you would use the one area where the US has a national health care system to suggest that it doesn't need a national system for everyone."

The insurance companies *would* insure old people if they were left too it. They would just have to pay higher premiums and several countries do have insurance companies that look at lifetime payments.

Posted by ScottH | July 2, 2007 11:26 AM:"The fact that you just accept the "market logic" of the bureaucracy that actively works against you just takes my breath away. It doesn't bother you that many times the result is at best the same or worse as long as it's some company whose sole purpose is to make money by minimizing the amount of money paid for your health, but the idea of a government bureaucrat makes you wet yourself in fear."

I see the justice is closing a hospital because it does not make money. It is extremely annoying to see a hospital closed because it is in a safe Conservative seat while another hospital in a marginal Government one is given lots of money. It does not make me "wet myself with fear" - and you damage your credibility by being so childish - it makes me irritated that politicians care more about being re-elected than sensible health care outcomes.

Posted by ScottH | July 2, 2007 11:26 AM:"Can't we just agree that both are unpleasant, but the fact that the government bureaucrat will not be getting bonuses to deny coverage makes that bureaucrat likely to be more fair to you?"

What makes you think that a government bureaucrat will not be getting bonuses? The present British government pays bonuses for adoptions. The result has been, as you could predict, a massive jump in the number of children taken from parents and put up for adoption. I prefer choice and the idea that I could dump my HMO and find a better one. I admit that it is mostly an idea, but it is not a bad idea. Government health care is one big State run monopoly HMO. How is that useful?

Posted by HeiGou | July 2, 2007 12:27 PM

From CNN "Sicko" also ignores a handful of good things about the American system

CNN runs this story (or something very similar) on air with the tag "fact checking" and also includes factchecking the weblink. Unless Moore states somewhere in the movie or an interview that his movie contains all relevant information about healthcare in America talking about all the stuff he could have included isn't fact checking.

It's all fair to bring up whatever you want to say Moore misses the point, but tons of criticism falsely suggests he's lying.

Posted by ChrisB | July 2, 2007 2:15 PM

"The business of America is business," remember? Why should health care be different?

Quick answer: why the heck not?

The history of fire services run as all-American 'businesses' is instructive.

Posted by pseudonymous in nc | July 2, 2007 4:33 PM

singapore,

What you don´t comment is the following: it seems thee is a pattern there, and that the US don´t follow it: they have to be excluded more often than not for the regression analysis.

I only "pattern" I was pointing to is the fact that many other OECD countries also fund significant fractions of their health care systems through private insurance. This includes France, whose health care system seems to be widely admired by proponents of reform in the U.S. So why this obsession with eliminating the "profit motive" from health care funding in the U.S.? And why is the "profit motive" supposed to be a fatal flaw in the funding side of health care, but not the delivery side?

The US and Switzerland are 2 of the 3 countries with the less public financing and the 2 countries where Private Insurance are managing the most money, and the 2 are spending - by far!-the most in absolute term (% of GDP).
So much for the efficiency of private companies in the health financing "market".

Huh? How does the premise "spending the most money" support the conclusion "not as efficient?" Cost-efficiency means "bang for the buck" not "number of bucks spent."

Posted by Mixner | July 2, 2007 9:42 PM