October 30, 2007
A test case for the media
Paul Krugman has attacked Rudy Giuliani for a dishonest ad on health care–or perhaps an ignorant one, as the case may be. This is a test for the media, as well as a scandal in its own right, Paul says. Will those feckless reporters and editors at The New York Times call Giuliani to account for this? Probably not, seems to be Paul’s opinion:
OK, Rudy Giuliani has just released an ad claiming that the survival rate from prostate cancer is much higher in America than in Britain, thus proving the failure of socialized medicine.
The problem is that his claim is just plain false. In fact, mortality rates from prostate cancer are almost the same in America and Britain.
So, will this get as much attention as, say, the Edwards haircut or the Hillary laugh? Will it get any coverage at all? Bear in mind that health care is the central domestic issue of this election — and Rudy has just showed that he doesn’t know a thing about it.
Giuliani’s claims in the ad are indeed misleading. First, prostate cancer is a very bad example. Worse, in my view, is the implication that his Democratic opponents are proposing "socialised medicine" remotely similar to Britain’s NHS. That can only be a deliberate deception.
To say that prostate cancer survival rates are much higher in the US than in England is not "just plain false", however. It is just plain true.
Five-year survival rates are higher in both America and England than Giuliani said. In the United States they stand at close to 100 per cent. In England they are 25 points lower. Figures for prostate cancer are notoriously misleading, though, because early detection (at which the US excels) delivers little improvement in mortality. Chiefly because of better diagnosis, America records a far higher incidence of prostate cancer–and nearly all of those early-detected cases survive five years. Men with prostate cancer, which develops slowly, often die of something else. If you are a man with prostate cancer, it may not matter very much whether your cancer is diagnosed early, or whether you live in Britain or America.
But does Paul therefore think that cancer survival rates, correctly measured, are similar for all cancers, including those for which early detection is important? If so, he is mistaken. See this report, entitled "Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States" (and remember that England’s rates, not broken out, are among the worst in Europe).
Taking recent figures, female five-year cancer survival rates are 62.9 per cent on average in the US and 52.7 per cent in England. To compare America’s privately insured with England’s NHS patients, you’d need to bump up that American survival rate a bit (the uninsured most likely have lower survival rates–otherwise why worry about universal coverage) and bump down the English one (because some Brits have private insurance, and so buy better care).
Nationally, American cancer survival rates are significantly better. Certainly not by the 40-point margin Giuliani implied, but still. And the politically salient question is this: If you have cancer, would you rather be an American with insurance or an Englishman without? The answer is obvious.
Which is more misleading, Giuliani’s ad or Paul Krugman’s assault on it? I’d say the ad has the edge for deception, but there isn’t much in it.
In your fourth paragraph you point out that survival rates depend on the stage at which the disease is discovered.
Having pointed out the problem with survival rates, you then use them to answer a question about outcomes “correctly measured”. I find this quite confusing.
Population death rates are correct measure to use for comparison of systems. I don’t know what they are; but, if you wish you make your comparison, you should find out.
Posted by: Reader | October 31st, 2007 at 4:29 am | Report this commentThis is an altogether bizarre reply. Krugman’s claims concern *prostate* cancer, not cancer in general. You have not refuted those claims in any way.
Posted by: js | October 31st, 2007 at 6:14 am | Report this commentEr - you can’t be an Englishman without insurance. They don’t exist.
Posted by: jasper emmering | October 31st, 2007 at 8:50 am | Report this comment“Which is more misleading, Giuliani’s ad or Paul Krugman’s assault on it? I’d say the ad has the edge for deception, but there isn’t much in it.”
I’d give it to Krugman. Giuliani’s ad overstates his position, but Krugman is just wrong.
Posted by: Tom | October 31st, 2007 at 12:49 pm | Report this commentThere is no nation of England, there is the UK, or the United Kingdom of Great Britain and Northern Ireland, which includes Scotland and Wales and England and some would say Cornwall, all the citizens of which are British. The Brits do not have socialized health insurance, they have something much better: socailized health care, so it is apples and oranges to compare the sub-set of priveleged Americans who actually have health insurance with all the “English” all of whom have tax-paid health care. The salient question if you have prostate cancer should be would you rather be in America or England? And the answer to that has not been addressed, but I can tell you that I would rather be any “Englishman” than an American without health insurance.
Posted by: Ian | October 31st, 2007 at 3:16 pm | Report this commentMr. Crook’s criticisms of Paul Krugman are not even internally consistent, much less supported by fact.
1. The statement “If you are a man with prostate cancer, it may not matter very much whether your cancer is diagnosed early, or whether you live in Britain or America” implies that the survival rates are very similar.
2. The further implication is that Mr. Crook knows the true incidence in each country, which are clouded by differences in diagnostic methodology. In reality, there may be real differences in incidence due to differences in the environment, nurture, genetic variation, and so on. Therefore, the true incidence in each country is unknown.
3. Mr. Crook provides no citations for his assertions, while Mr. Krugman does.
4. The debate over whether PSA antigen testing affects survival is not settled, as a review of recent literature will confirm.
5. Since Mr. Crook asserts that diagnosis is much better in the United States than in the UK, it is disingenuous to shift from overall survival rates to 5-year survival rates. The Exra Klein reference is clearly to overall mortality.
I was very disappointed by this piece, especially considering the nice promotion this site received from Brad DeLong.
Posted by: Charles | October 31st, 2007 at 4:25 pm | Report this commentIan,
You certainly need to get a little more educated on the health insurance stats in the US. Your comment, “…subset of privileged americans who have health insurance…” was hilarious.
Do you mean the 250+ million of us who do have health insurance? As opposed to the misleading and often quoted 45 million who allegedly do not?
Tell you what: I will try and not make fun of your system of medical treatment (ok, other than a few comments about teeth) if you don’t do the same about ours.
Posted by: James | November 1st, 2007 at 6:16 pm | Report this commentAs an economist, Clive, wouldn’t you expect the US to have better health outcomes - whatever its system - given that the OECD estimates it spends $5711 per head compared to $2317 in the UK?
Posted by: DavidS | November 1st, 2007 at 7:57 pm | Report this commentJames - ‘Do you mean the 250+ million of us who do have health insurance? As opposed to the misleading and often quoted 45 million who allegedly do not?’
A third of all adult Americans are uninsured or underinsured in health. It’s just not true to assume all the ‘insured’ have equal access to gold standard care.
Posted by: Marcb | November 1st, 2007 at 8:03 pm | Report this commentIt seems to me that some of the posters here including the author of this article lack the understanding of even basic epidemiology. For the record, I don’t have strong opinions of UK vs US health care; I have relatives in Germany and I see some problems with their system. I do, however, take exception with misuse of statistics.
The guidelines for screening and practices are different in the US and in the UK, this is a known fact. It is not clear how much of an improvement in mortality is due to these differences.
Comparing ratio of cured to diagnosed is not an acceptable metric when one group is screened a lot more than the other; mortality rate per population is.
For example, regardless of whether PSA works or not, there is no question that it results in overdiagnosis: detections of very early and very slow growing cancers (or even non-progressive cancers) that would’ve never spread in one’s lifetime if left undetected. Overdiagnosis is a known and accepted side effect of screening, the only question is how large it is, but it is very difficult to estimate (for example estimates for mammography vary from 5 to 40%). Since non-progressive cases are easy to cure as they wouldn’t have spread anyway in one’s lifetime, this increases the ratio of cured to detected by adding the same positive number to both nominator and denominator and makes the comparison of survival rates as a percentage of cured/detected invalid. If you don’t understand it, consider this: let’s say you have 8 cases detected in the UK and 4 cured. Let’s say because of early detection you have 2 additional cases detected in the US, but as they never become apparent in person’s lifetime they represent overdiagnosis. We’ll get the ratio of cured/detected in the UK as 4/8 = 1/2 = 50% and the ratio of cured/detected in the US (4+2)/(8+2) = 6/10 or 60%. The US number looks better, but the number of people who die is still the same - 4. Not all additional cases detected in the US may be overdiagnosis, but this example shows how misleading the comparison between survival rates can be.
Additionally, it is ridiculous, to compare 5-year survival rates when in one case there is a lot more screening than in the other. If you don’t understand it - here is a simple example. Let’s say two men died at age 50 from cancer, in one case it is diagnosed early at age 43 because of a test, in another - at age 47. Who is better off? The end result is the same, but the former survived for more than 5 years. This is called lead-time bias, and this is another reason why overall mortality reduction is the only acceptable measure of a screening test effectiveness in randomised trials.
Posted by: Diora | November 2nd, 2007 at 3:36 am | Report this commentGiuliani received his excellent prostate cancer medical care from the evil Big-Government-Welfare-State. It was provided by the taxpayers of the City of New York, of which Giuliani was then the mayor. Like other beneficiaries of Big Government socialized medicine in the U.S. Congress and the White House, he didn’t have to pay a penny. And yes, that Big Government medical care in the US is very good, which is why Senators and Congressmembers don’t complain very much about the state of US medical care. (Of course, they never stopped denouncing the Soviet nomenklatura’s access to privileged health care in the good old Evil Empire.)
Posted by: Mark | November 2nd, 2007 at 2:19 pm | Report this commentSo, if everything is so much better in the good ol’ USA, why do we rank 38th in mortality rates with shorter life spans than all of the western industrialized nations which have both some form of national health insurance and much lower overall health care expenditures per capita. Maybe we are spending too much money on denying people treatment (much higher administrative costs for private insurers compared to government insurers) and possibly too much spent on frivolous items (Botox injections, liposuction) and not enough on prevention and health maintenance.
Posted by: Alan J. Barnes | November 2nd, 2007 at 11:05 pm | Report this commentMark,
The reason the US has higher mortality is because of guns and cars. We have much higher incidence of deaths in auto accidents and by guns.
Posted by: Steven | November 7th, 2007 at 9:16 pm | Report this commentAlan J Barnes-
“So, if everything is so much better in the good ol’ USA, why do we rank 38th in mortality rates with shorter life spans than all of the western industrialized nations which have both some form of national health insurance and much lower overall health care expenditures per capita.”
Because the US records deaths that European countries don’t. Every baby that exits the womb and even some that don’t are recorded as a birth and life. When these babies die seconds, minutes, hours, days after birth, it is recorded as a death. Many of these similar cases are NOT recorded as a live birth and death in European countries, but instead are not recorded as a birth. This will certainly skew any general mortality rate in favor of those with less recording and accountability. Using straight mortality rates is a very poor indicator of a health care system.
I also think that most of you are simply making the wrong arguments. You keep comparing 2 FAILED systems. And trying to say one failure is better than the other. And the reason they are both failed? Government. Most health care systems are broken BECAUSE the government has gotten involved where only the doctor and patient should be involved. Get the government out of the way and cost will plummet and quality will skyrocket. If you think I’m wrong, please let me know where government involvement has improved a situation for the MAJORITY of people and where private industry failed in the same endeavor.
Posted by: Sean | November 8th, 2007 at 3:43 pm | Report this comment