Professor Frank is spending a month in Sweden – that is the
professorial gig, is it not? (Full
disclosure – my neurosurgeon father Henry Shenkin used to get red in the face
decrying the traveling predilections of professors while he, Henry, did real
work with real people under hard conditions. Programmed as I am, it’s hard to forget his feelings as I
hear about the visiting professor gig.)
While there, he asks health economist friends about the Swedish health
care system. Having lived in
Sweden for a year doing research on their health care system, and having
published about it twice in the New England Journal of Medicine decades ago,
and having followed health policy in the US for decades, this is something I
know something about. So when
Professor Frank takes out his economics glasses, and opines on the comparison
of the Swedish health care system with American care and Obamacare, my critical
faculties are engaged.
What I find is an ideological view of a liberal economist
that seems to combine a very superficial knowledge of both systems. Pretty much what one would expect from
someone on vacation – I mean, visiting professor – for a month and shooting the
shit with colleagues.
First, the Swedish health system is not ridden with
bureaucratic inefficiencies, they say, so Frank opines that Americans shouldn’t
fear it either. Oh, yeah? So if Swedish government can run it,
then American government can, too?
That’s not worthy of Frank. And he completely glosses over the fact that the power over
health care for the 9 million population in Sweden is in the Landstings, the
county governments. How would that
translate to the US? No answer
needed. The capacities of governments in different countries are different.
Second, compare infant mortality rates and male death rates
between ages 15 and 60, and America comes out short, which to Professor Frank
is an indictment of the United States health care system. That’s a poor argument. Infant mortality does little to measure
differences in health care systems in advanced countries. What it measures more is economic
disparities, and the US has a lot more poor people than Sweden. As to the male death rate, there is
recent evidence on this, which I think I have shared on this blog. The increased death rates for Americans
has to do with violence, suicide, and motor vehicle accidents, none of which
are attributable to the health care system. It does have to do with availability of guns, I imagine, and
most importantly with the number of miles traveled by car, which is much more
in the US than in Sweden. After
the age of 50 death rates of Americans are comparable to the most advanced
countries. So the argument of
poorer quality because of the organization of health care does not wash.
OK, after indicting the health care system on these flimsy
statistics he recants in the next paragraph, but in a silly way. He says that more Swedes commute by
bicycle and thus avoid obesity – actually, the public transport system
is the real difference, and obesity is not the issue, accidents are the
issue. And he mentions the income
disparity. But doesn’t this
destroy his argument in the paragraph before? Poor show.
Third, he commends Swedish large hospitals for efficiency,
and condemns American “boutique hospitals” for people with high cost health
plans. This is crap. The US has a lot of big hospitals, and
many of these are the worst offenders in cost – see UCLA, for instance. The problem with American health care
has something to do with efficiency, but more to do with prices. The largest hospitals in the US command
higher prices because of their mini-monopolies in local areas. And the proliferation of
under-utilized, high cost machines is less of a problem in the US than it used
to be. The problem here is lack of
regulation of technological proliferation and pricing, rather than the size of
hospitals. You have to have either
real competition or real regulation, each with its own strengths and
weaknesses. Sweden has state
ownership and control. The problem
in the US is we have neither effective regulation nor sufficient competition.
The tip-off on his ideology is in the riff on “boutique
hospitals.” These exist, but they
are probably cost-savers. One
important proposal for future health care organization calls for more and more
“centers of excellence,” some of which would be these very “boutique
hospitals.” He is just ideological
here, thinking that "boutique hospitals" are for the affluent only. Get Medicaid payments to competitive levels, and make Medicare payments rational, and there would be no problem.
Fourth, he says Sweden centralizes care so that more
operations are carried out by more experienced facilities and surgeons. That’s true, but this happens in
the US as well. Frank notes
parenthetically at the end of the article that there can be a three-month wait
in Sweden for a hip replacement, but says this is acceptable as a trade-off for
centralization. Maybe it is, but
what other inefficiencies from the patient point of view are there? I don’t know since I haven’t been there
in a long time, but I guarantee they are there. I remember, for instance, talking to Swedish friends about
their primary care. I said that
with the polyclinic system there had to be a decrease of personal
relationships. Yes, they said, but
isn’t objectivity a good thing, too, not to be swayed by the personal
relationship? I don’t think
Americans would agree.
Centralization has its problems that the Swedish system has tried to
address by introducing elements of competition – but we don’t hear any of that
in this article.
Fifth, he says that since Swedish care is non-profit and
they are charged with high quality mission, they won’t withhold care, as
for-profit institutions in the US will.
Whaaa? The problem with
for-profit is supposed to be doing too much, not too little! And the problem at Kaiser, a large
non-fee-for-service institution, is withholding care. Frank is severely off track here – it’s just ideology
talking.
Sixth, more hip-replacements in Sweden are attributed
positively to the fact that the system is well funded and care options are
generous. But his argument is
heads I win tails you lose. If
there were fewer hip replacements, he would say this is evidence of runaway
profit-mongering by operation-hungry surgeons and institutions in the US. I
think I know what he is trying to say here, that despite the capacity of a
state system to withhold care for financial reasons, that doesn’t seem to be
happening in Sweden if you take this one operation as a measure. But just citing one operation as a proxy for generosity and quality doesn't work. For
all we know, all those hip operations could be a result of the pressure from
the Swedish orthopods who want more and more work for their cadre, and more and
more residents – who knows?
I happen to be a Swedophile, and I think there is much in
Sweden worth emulating. If we were Swedes, it would probably work very well. We can certainly learn from some elements.
But to gloss over bureaucratization on the say-so of Swedish economists
reveals the essence of his one-sided view. And I hope I am not defending the American health care
system, which needs revolutionary change and is not likely to get it. But ideological columns like this are
not likely to advance the cause.
Like my father, it gets me so mad when somebody thinks he is
so smart he can plop himself down for paid-for month in a foreign country and
talk to some economist friends, and come up with something worth saying in a
New York Times column. I’m sure
he’s smart, and he is probably a nice guy, and our ideas on health care are
probably not very different, but this article is, well, let’s just say, not
fully thought out.
Budd Shenkin
