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International Healthcare Comparisons: Green Grass, Brown Grass, All Around the Hill

Robert F. Graboyes, MSHA, PhDNFIB | 1201 F Street NW, Suite 200 | Washington, DC 20004

bob.graboyes@nfib.org | 202.314.2063

Personal: rfgraboyes@gmail.com | www.robertgraboyes.com

Revised slides from GIC talk, Philadelphia, 1/14/09

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Viral factoids do not a cure make• U.S. healthcare has serious problems• We look inward for solutions and are found

wanting• We can learn from other countries• But not if we romanticize• Not if we hunt for the perfect off-the-rack system • Not if we commit every data-gathering and data-

processing fallacy available

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Small business has a deep interest in healthcare reform

• Small business is the source of:– 70% of job growth in recent years– All job growth right now

• Premiums up rapidly• Premiums higher to begin with• Most of the uninsured

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It’s the economics, stupid• Economics means you can’t escape choices• Worthy, but conflicting goals

– Access (who? what? where? when? why?)– Insulation (catastrophic? first dollar?)– Affordability (says who?)

• Economic problem: pick any two• Growing mood on universal access

– We can do better– We can’t do perfectly

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What you know that just ain’t so• Infant mortality comparisons

– Different countries measure differently– With the same methodologies, US is on par

• Administrative costs vs. DWL– Here, healthcare has large billing and

collection costs; there, it’s high tax rates• Equality: Britain’s postcode lottery

There’s no Mr. Sandman

• “Mr. Sandman make me a dream”– Cute, lips, eyes, heart, hair

• Single-payers cherry-picking individual aspects of different countries– France’s acute care– Canada’s drug prices– Etc.

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3 apples + 2 oranges = 37• Glen Whitman, Cato Institute, “WHO’s Fooling Who?”

• “U.S. ranks 37th in health care”• WHO’s statistic is misleading

– Financial fairness– Health distribution– Responsiveness distribution– One index: high cost reflected as poor health status– Statistical margins of error ignored– Healthcare health

• Lifespan deficiency partly murders, car wrecks, smoking, etc.

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It depends who you ask.• Citing people YOU know or meet is problematic

– Wealthy American tourists, their overseas friends and their drinking companions in foreign pubs do not constitute an unbiased population sample

– 3 most common reasons for visits– “People I met seemed so pleased with their

healthcare.”– Could it be the particular bar you frequented?– Care in Inuit areas, rural areas, etc.

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It depends where you ask• Different countries answer surveys

differently• Japanese parents vs. Minnesota parents

on kids’ math educations• Cuba: Potemkin hospitals• Canadian attitudes

– The Shipping News– What do you like best about your country?– Settling of the West

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Results first, data later• Accusation by one single-payer backer

– deductibles cause Americans to skimp on dental care

– Some guy who did so has bad teeth– Therefore, first-dollar coverage will give us all

great teeth • Problem with this theory

– Britain: little cost-sharing, but lots of bad teeth– Switzerland: almost no insurance, but great

teeth

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Our past is their future• Obese Americans unique and mocked• But we were just first to get there, thanks

to our higher incomes and earlier diffusion of technologies

• But, obesity on rise in France, China, etc.• On the other hand, America laughs at

other countries’ queuing and rationing, but that could be our future

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Sometimes, our grass is greener• We rail against American higher costs, BUT …• Foreign medical salaries (France $55,000/year)• NICE / NASTY

– Cost per QALY and the elderly– Queuing– Post-operative infection

• Canadian Supreme Court: "Access to a waiting list is not access to health care.“– Sylvia de Vries: 34-pound tumor– High-risk pregnancies

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Other countries emulating us• John Goodman, Gerald Musgrave, Devon Herrick, Lives at

Risk

• Britain: Millions with private insurance• Britain: NHS using private hospitals to

reduce queues• Germany: ability to choose among

competing insurers• Netherlands: managed competition• Canada: U.S. as safety valve

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No thrift shop • Challenge is to look for elements of other

systems that hold promise– Switzerland: competitive private insurance– South Korea: rapid rise in coverage– South Africa: use of HSAs– Netherlands: prospective risk-sharing– France: acute care– India / Thailand / Costa Rica: medical tourism

Conclusion• No one has it “right”• No one ever will• We have our problems• They have their problems• We can do better• They can do better• Every system will have holes, and there

will always be room for improvement

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Robert Graboyes: Mini-CVEducation• University of Virginia: BA • College of William and Mary: MA • Virginia Commonwealth University: MSHA • Columbia University: MPhil, PhDCurrently• National Federation of Independent Business (2007-date): Senior Healthcare Advisor• Virginia Commonwealth University (1999-date): Adjunct Associate Professor • University of Virginia (2005-date): Clinical Associate Professor • George Mason University (2008-date): Adjunct ProfessorPreviously• University of Richmond (2001-2007): Economics professor• Federal Reserve Bank of Richmond (1989-2002): Economist/manager• Virginia Department of Taxation (1989): Economist, revenue forecaster • Chase Manhattan Bank (1983-1988) Economist/2VP; Economist for Sub-Saharan Africa;

asset portfolio modelerMiscellany• American Institute for Economic Research: Research Fellow (2007)• Kazakhstan School of Public Health: Visiting Scholar (2000, 2007)• National Association for Business Economics: Chair, national Health Economics

Roundtable (2004-06); Chapter President, Richmond, VA (1989-1991)