A Couple of Interesting Pieces . . .

from the new JAMA. I'm not even going to bother continuing to express my annoyance about it being subscription only. (Whoops! I guess I just did.) Anyway, you common rabble will just have to take my word for it about the following.

Joseph Ross, Elizabeth Bradley, and Susan Busch use data from the Behavioral Risk Factor Surveillance System (which is misnamed, it's not a surveillance system but a telephone survey) to examine use of preventive health services by people without insurance, including the relatively affluent. It turns out that while more affluent people in general are more likely to use preventive services, the gap between the insured and uninsured is just as large among the well-to-do as it is among the impecunious.

Specifically, 83% of uninsured women with incomes under $15,000/year got cervical cancer screening (Pap tests) as recommended; so did 84% of uninsured women with incomes above $75,000. (Yup, some well-to-do people choose not to buy health insurance.) While 67% of high income women got mammograms compared with 56% of low income women, the gap between the insured and uninsured was just as great at both levels. The pattern for colon cancer screening was similar -- 48% of uninsured high income people got them as recommended, compared with 65% of insured high income people.

In present policy debates, this is important because it proves, beyond a reasonable doubt, the utter folly of the Republican push to get people to buy high-deductible insurance plans that don't pay for routine care; and pay for routine care out of tax-deductible accounts. That is supposed to "contain" health care costs by making consumers think twice about spending. The problem is, as should be obvious, that consumers forego spending on services that will prevent far more expensive disease -- even when they can afford them. Q.E.D.

Moving on, before lining your bird cage you may have read about the study by Banks, Marmot, Oldfield and Smith comparing health status in the U.S. and the U.K. Before I say anything else, I must protest that they made the bizarre decision, which the editors bizarrely endorsed, to include only white, non-Hispanic people in their data from both countries, supposedly to avoid the confusion that would be caused by the differential health status of ethnic minorities. Uhh, those are also actually people who live in and are in most cases citizens of those countries. It would have been very easy to include them and simply account for the differences in the analysis; and the health status of minorities in both countries is obviously a matter of compelling public concern. I will not hesitate to use the R word.

That said, the differences are dramatic. In both countries, there are gradients in health status according to social class (income and schooling), but among comparable age groups, English people (by which in this case we mean English people of European ancestry) are much healthier than Americans (by which we mean Murrkins of European ancestry). The data includes information from actual physical examinations as well as self-reports, so it is pretty bullet proof. 12.5% of Murrkins age 55-64 have diabetes, compared with 7.2% of Anglo-Saxon and Celtic Subjects of Her Majesty (ASCSHM). 42.4% of Murrkins have hypertension, compared with 35% of ASCSHM. 5.4% of Murrkins have had a heart attack, compared with 4.2% of ASCSHM. And on and on. In fact, the rate of diabetes among high income Murrkins is much higher than the rate among low income ASCSHM.

Why is this? While it is true that 100% of ASCSHM have life-long health insurance, whereas many Murrkins do not, that does little to account for the disparities, which don't have a whole lot to do with health care anyway. Murrkins started to get fatter sooner, which may make some difference; and social inequality is greater in the U.S., which has an as yet not fully explained relationshp to population health status (but doesn't explain why wealthy Murrkins are about as unhealth as poor ASCHSM).

Don't forget, the Brits spend half as much on health care as we do. We're obviously wasting our money.