Arrogance and mediocrity

It’s hard to improve policing in the UK because everyone is supposed to pretend to believe that Britain has “the best police in the world.” Sounds like our health care debate, doesn’t it?

I’m on my way back to LA tomorrow after a quick trip to London. Today included a meeting with a senior figure in the crime-policy world here, who was reflecting on how hard it is to improve the British police service. He identified, as a central problem, what he called “BPW”: the need to start every speech about policing and crime with the (by now transparently false) statement that the UK has the “best police in the world.”

That reminded me of the American health care debate, where the opponents of progress always start out with the (again, transparently false) claim that the U.S. has the best health care system in the world, when in fact it’s a notable under-performer, despite its astounding financial bloat. We certainly have the best-paid hospital directors and health-insurance CEO’s in the world, and the best-paid specialists in invasive procedures. But it’s hardly the best system from the viewpoint of the patient’s wallet or the patient’s lifespan.

It’s the old story: the first step in fixing something is noticing that it’s broken.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact:

36 thoughts on “Arrogance and mediocrity”

  1. If you measure “best” by how much money doctors make and how many medical innovations come out of the USA, we are #1. Sadly, so many people don’t have access to basic medical care that’s been around since the 19th century. If I’m poor, and I break my arm, I need a skilled professional to set my arm in plaster and make sure it heals correctly. Doctors have known how to do that since my grandfather was born, or before, and I’d wager a reasonable sum that the technology for fixing simple fractures hasn’t seen much innovation since then. Imaging technology has improved, but that which was available in 1950 was more than sufficient for diagnosing, setting, and verifying the correct setting of simple long bone fractures. I’m not against innovation, but it’s no substitute for access.

  2. As with many things in the US, our health care is innovative and superlative. But, again as with many things in the US, it is also oligarchic. For a wide variety of ailments, we do have the best care in the world, if you can afford it.

    1. While we’re shooting down jingoism in rhetoric about medical care, let’s also call out other falsehoods like “if you can afford it”.

      In almost every county in America, anyone can get free medical care. Yes, county hospital patients face waiting periods, and rationing of care, and get little choice in treatment options. But that’s true of all government run medical systems – including the National Health Service in the UK.

      Let’s end the jingoism, and let’s end the unwarranted pessimism too.

      1. No, actually it is very true that medical care is often too expensive for people. So while we are shooting out jingoism, let’s stop lying as well.

      2. This simply isn’t true. Yes, once you’re diagnosed it may be possible to get treated for free in county hospitals, though you will (uniquely to the US) be required first to bankrupt yourself, and I suspect even this is an overly optimistic gloss on events. Certainly, the rationing there is far, far worse than even the scare-stories used to denigrate the NHS.

        But the US is uniquely bad in access to medical access, not just care. Look for example at the recent story of a woman who waited until she’d achieved Medicare eligibility to have a 51 lb tumor removed. Or the many people who live with pain and go undiagnosed because they cannot see a doctor or get non-emergent care, or go untreated because they can’t stop working and don’t want to pauperize their families.

        1. No. County hospitals chere based on your income not the actual cost of care. And no. Access is not a unique medical problem. The UK has horrendous years long wait times for dental work and most surgeries. County hospitals have vastly shorter wait times as UK hospitals.

          1. Allow me to comment here, since I am actually living in the UK and have been the recipient of NHS healthcare (in particular, I’ve had two babies here).

            In short, your claim about NHS waiting times is misleading, though there is a kernel of truth to it.

            First of all, pretty much any and all waiting times in the UK are due to the NHS being run on a scarily low budget. If we were to double the UK’s per capita medical expenses (which would bring it roughly on par with the United States as a percentage of GDP), waiting lists would all but disappear (similar to France, which also runs a fully socialized system, or Germany, which runs a system that is de facto very similar to single payer). In the end, you get what you pay for.

            Second, no, the UK does not have years long waiting times for dental work and most surgeries. The maximum wait time allowed under the NHS constitution is 18 weeks. If you don’t get treatment after that time, you have a right to be referred to an alternative provider that will provide more timely treatment. This will not cost you any money, but you have to apply for it specifically with your NHS trust or health authority, and I suspect that a lot of people are unaware of that option. If you’re waiting a year for treatment, you’re generally not exercising your rights under the NHS constitution.

            To get more technical, there are actually four versions of the NHS, NHS England, NHS Scotland, NHS Wales, and NHS Northern Ireland. What I described above is the situation in England. In Scotland, for example, 96.8% of all those needing outpatient treatment were receiving treatment within 12 weeks and 93.6% of all patients needing inpatient treatment and day cases were receiving treatment within 9 weeks or less.

            These wait times also only apply to non-urgent procedures. Emergency treatment in particular you get on a walk-in basis. And you can generally see a primary care professional within 24 hours and a primary care doctor within 48 hours for non-urgent consultations.

            Note that waiting times aren’t necessarily much better in America (though that is hard to know, because their is not much data being collected), and in particular that it often takes a lot longer to see a doctor in the first place.

      3. You can get excellent free medical care if you have the appropriate acute problem, and are lucky enough to have that problem in the right place. But if it isn’t acute intervention, free medical care is damned hard to get. Where is the free care for, say, Crohn’s–or dental problems?

          1. In almost every county in America, anyone can get free medical care.

            Free? You mean I don’t even have to offer to barter my stoutest chicken?
            Nothing is free sonny boy. There is no such thing as a free lunch: not even when the construct temporarily serves your spurious wingnut point of view.
            About the only thing that has been free up to now has been:

            1) The chemical energy stored in the planet’s crust that your culture pumps and mines as a sort of free industrial food.
            Without which you still be harnessed (“rightfully” so) to the ass end of a ox doing meaningful work for once in your life…

            2) The “free ride” your culture has taken on polluting the atmosphere as if it was a common area capable of infinite absorption.

            But payback time is coming for all that too.
            Only freaks think you get something for nothing…

          2. This is simply not true. Our county of 1.5 million maintained a hospital and clinic for the “indigent” for over 150 years, but the last round of budget cuts essentially shut down the hospital. The clinic has been reduced to two storefronts at the most inaccessible locations in the county, open 10-5 M-F and treating only a limited range of conditions. There simply isn’t any free government-provided medical care in the county (except for VA) any more, and the only thing that comes close is begging the Catholics to take you on as a charity case which is not only demeaning but uncertain.


      4. No, if you can afford it adequately sums up the state of health care in the United States of America, circa 2012. County hospitals don’t exist everywhere, and do not provide income-based care anywhere unless it is mandated under state laws.

        The controlling federal statute is EMTALA, the Emergency Medical Treatment and Active Labor Act. It was part of the 1986 Comprehensive Omnibus Budget Reconciliation Act (COBRA). It requires all hospitals receiving Federal funds to provide treatment for medical emergencies to patients without regard to citizenship status or ability to pay. Because Medicare/Medicaid reimbursement meets the definition of Federal funds, essentially all hospitals with emergency departments are covered. Patients may be discharged only after they have medically stabilized, on their consent (against medical advice), or on transfer to a facility capable of treating their condition.

        In other words, if you a diabetic is brought in in a diabetic coma, the ER must treat them. If you show with uncontrolled blood glucose levels, they won’t treat if you can’t pay. Many (not all) parts of the country have clinics that care for patients with fees based on incomes (“free” clinics), but even these clinics don’t (and can’t) provide care that requires hospital facilities. If you show up with appendicitis at a “free” clinic, you may be diagnosed. You won’t receive the standard of North American care for appendicitis, though. That is surgery, and you won’t get surgery until someone (likely at the “free” clinic) has arranged for a surgeon and local hospital to provide reduced cost care. Or until your appendix bursts and it becomes a medical emergency. Of course, that might kill you (it is a life-threatening condition), but that’s beside the point isn’t it?

        Meantime, we have sufficient idle capacity in this country that if you have carpal tunnel syndrome and:
        (1) good health insurance;
        (2) you decide that you’ve suffered enough with this chronic condition; and,
        (3) your orthopedic surgeon recommends surgery;
        you can have surgery later this week. Unless you see the surgeon on Friday (or maybe Thursday): in that case you’ll have to wait until Monday (or maybe Tuesday).

        Meanwhile, we spend more than twice per capita than any other industrialized country. (If you count is as a fraction of GDP we are still way ahead of all other industrialized countries.) What is the return on our investment? Mediocre health measures at best. Our life expectancy at birth lags behind most of the G20. Our vaccination rates are shameful. Our neonatal mortality rate and infant death rates are also shameful. We know how to fix these things: we simply lack the collective will in Congress to do it.

        With health care, as with education, Mr. Rmoney [sic] believes that we are entitled to all we can (personally) afford.

        1. Spot on. Anyone who spouts off about “illegals” being able to receive health care at any ER that “Amuricuns” can’t get hasn’t been paying attention. There is no provision for treating non-emergency or chronic conditions. People die needlessly and prematurely of treatable conditions every day because they can’t get treatment and medications for cancer, diabetes, heart disease, and anything else you can think of. Even if they are homeless and have absolutely NO income to go bankrupt ON, they can’t get appropriate ongoing treatment and follow-up. You might get bypass surgery or stents if you have a heart attack and make it to an ER in time, but you aren’t going to get the diagnosis or medications to prevent that attack or the follow-up needed to prevent the next one.

          I was talking to a friend with cancer the other day, and she was saying how thankful she is for Medicare because of the high cost of her treatments. But she HATES Obama and “Obamacare” and wouldn’t vote for him if the R candidate was an avowed Antichrist. Try talking to people like that. You assume their own situation “should” have provided some insight, and people of my generation who had good insurance when we were employed and who now have Medicare ought to be the first in line to try to make sure our younger friends and relatives have the health benefits we enjoy(ed). Even if those benefits are provided through different channels than those we are used to. But obviously, too many in my age group don’t seem to get it that the world is a different place than it was when we were younger and when everybody we knew took for granted good employer-provided insurance, and when everybody with at least a high-school diploma could get a “good” job and hope to retire from it, often after many promotions and pay raises.

      5. “In almost every county in America, anyone can get free medical care.”

        No. Hospitals are required to offer limited care.

        And browse for those situations where somebody sets up a free clinic – note, offering limited care. Thousands of people camp out all night long, in hopes of very basic care.

        1. I am not sure where Jeff is getting his information, or his certainty that “free” medical care is offered in every county in the US.

          First, as a commenter said above, yes you may be able to get free medical care, but only if you bankrupt yourself in the process–destroying your financial health and risking being sent to the now-resurgent debtor’s prisons. (–280–the-return-of-debtors–prisons.html)

          Anyone could set up appointments with specialists for procedures and surgeries and then just not pay the bills, or plead hardship. They would then face an interminable nightmare of collections, bankruptcies, and other indignities. But for honest Americans who have the misfortune of being sick, access to legal and affordable health care is the only humane option.

          Second, that would be…socialism! as the Right continually tells us. We all know that helping others is not allowed in modern America, because helping others is a socialist idea.

          Here’s how a deeply misanthropic acquaintance of mine put it on Facebook when ACA was upheld: “Back to work now, I have to earn as much as I can so that I may pay for others healthcare now…America is all about people paving their own way, not leeching off the work of others…When I see everyone working together I will be on board with you. I see a lot of people with their hands out…Like I said, off to work I go for others. Smells like socialism to me….” His attitude (shared by many) should make us all just joyful for the future of America.

  3. I’ve lived away from the UK for decades, but is there really such a widespread credulity by the British public in the excellence of the plod,in spite of repeated scandals in the Met, miscarriags of justice, the flops by the SFIO, etc.? I’ll grant the parochial self-belief among the police themselves, and politicians’ near-universal appeasement of them in order to look “tough on crime”.

    One factor reinforcing police parochialism is the low European mobility of policemen ans other public-sector workers like teachers. They have largely escaped the European directives opening up closed national labour markets, for instance to doctors and nurses. The barriers could have been countered by large-scale exchange and in-service training schemes, but these havn’t happened.

    1. My impression has been that people here in Scotland at least haven’t really regarded the police as either exceptionally good nor exceptionally bad. In short, nobody was exactly shocked to find out about corruption at Scotland Yard, but at the same time nobody seems to be thinking that police officers in general are for sale or that we’d be better off without them.

      My own limited interaction with the police here has been one of unremarkable normality.

  4. I lived in London in 1987. Growing up in America, I had always assumed that the British did, in fact, have the greatest police force in the world–better than even our FBI. I was extremely shocked to meet many people who considered the Metropolitan Police force to be racist, incompetent, and corrupt, although the corruption more often took the form of bending the law to the benefit of the rich and powerful, than accepting bribes.

    As the Murdoch scandals unfold, it’s becoming increasingly clear that corruption, at least at the senior level, has become the rule rather than the exception.

  5. I have been thinking about how to take this on. One can honestly say that the U.S. has a very generous share of the world’s best medical facilities, equipment, doctors, nurses, and medical professionals of every kind. Perhaps the next line should be, approximately, “When it comes to good, smart, efficient, life-saving health care systems, Europeans and other foreigners are kicking America’s ass [or audience-tailored euphemism]. The reason for that is politicians and others who won’t let America be as great and exceptional in the 21st Century as it was in the 20th — and don’t mind setting us up to be laughed at by foreigners.” That is probably not how most Samefactsers would phrase it in private conversation, but we are going for the “swing voters” here. Bear in mind, however, that a negligible portion of the opposition to progress here is based on considered admiration for the current U.S. “system”. It is an alliance between the beneficiaries of the current system’s defects, and those who simply want to deny any victory to a Democratic president.

    1. I think you miss another very large faction opposing “progress” – people who believe the federal government should have limited powers. These people would use the word regress.

      1. Republican are for smaller government in Democratic administrations, don’t care much in Republican administrations. Do you see a dedicated campaign to repeal Medicare, or the VA medical programs? If health care reform had been proposed by a Republican and loaded with enough hits to Democratic constituencies, Republican would have been all for it. And, witness the Bush Medicare drug expansion, it would not have to be “paid for”.

        1. Seconding Ken here – we just saw how the GOP and the right regarded power when they had the upper hand in the Bush II reign of garbage, and at the state level in many states.

          By now, Jeff, it’s not honestly possible to believe that the right is for limited government.

      2. I am very much in favor of the federal government having limited powers. However, I also believe that those powers should be tailored to the needs of the 21st century, not the 18th. Smart as the Founding Fathers were, healthcare in the 18th century (the time of amputations as preventive care and barber-surgeons) was very different from what it is now.

        I’m also generally more concerned about state governments abusing their power than the federal government, since state governments thave traditionally been far more likely to pass intrusive laws.

      3. I love the limited federal government argument. So many Americans are so ignorant of our history that they are unaware that this was tried and failed miserably. In 1776 and 1777, the Articles of Confederation were drawn up to create the U.S. government and legitimize the war. In the AoC, the states were given considerable power, while the federal government was intentionally kept small and weak – certainly less powerful than the states.

        This was the way America existed for its first decade – a nation ruled by states’ rights with a limited federal government. This appears to be Jeff’s dream for the future. However, in practice, the results were so dysfunctional and divisive that it was an unmitigated disaster. The “Founding Fathers” quietly slipped away to Philadelphia in 1787 to begin work and discussion on an alternative template for government, this one giving primary power to a central federal government, and subordinate powers to the states. After four months of work, they approved and signed the Constitution of the United States of America and put it out for states to ratify (it required 9 and it succeeded). That system of strong federal government and subordinate state governments has been with us since 1787 and every indication in their writing (try reading the Federalist Papers – essays supporting the new Constitution by Alexander Hamilton, James Madison, and, to a lesser extent, John Jay) was that the “United” States of America would have collapsed into separate fiefdoms under States Rights, just like they were as the original colonies.

    2. Of course, one of the major unstated objections that the Republicans are probably pissed that the Affordable Health Care Bill mandates that federal employees, including Senators, Representatives, and their staffs, as of January 1, 2014, will no longer be covered under the Federal Employees Health Benefits Program, where two-thirds of the cost is subsidized by the rest of us taxpayers. They will have to get their insurance through the exchange, buy their own policies on the for-pay “open market” or other sources. I think that those who make the laws for the rest of us shouldn’t be exempted from their effects. Perhaps, with the taxpayers no longer ponying up for the bulk of their health insurance, Mitch McConnell and John Boehner will opt for an HMO plan for himself and his family. Of course, this is – to them, but not the taxpayers – a good reason to get Romney elected so he will tend to his party’s and big contributors’ wishes and repeal the bill.

  6. Brazil is instituting a new practice in its prisons to encourage prisoners to read: forty-eight days reduced from an inmate’s sentence for every twelve books read annually. 

  7. I met a French educator once who ran a distance-learning programme. He said that his most assiduous students were prisoners, because they won remission for every qualification earned. This seems harder to game than the Brazilian book-reading scheme: what counts as reading?

    1. I suspect it doesn’t matter: Brazil’s program amounts to a potential almost-15% reduction in sentence for good behavior, albeit a certain sort of good behavior. Seen on that basis, the details of which books becomes less important. In any case, even if every one of the books is appalling a comfortably literate person must be more employable than an illiterate person.

  8. I just want to relate another story I personally witnessed at a company I consulted to for several years recently. The HR department had managed to snag a better-than-average insurance policy, with both PPO and HMO levels. This was in place when I started working with them, and all of the employees thought they were pretty lucky. Then, an employee who had been with the company since its founding as a small entrepreneurial enterprise, learned that his 2-year-old daughter had been diagnosed with acute lymphoblastic leukemia. This is a fast-moving leukemia most commonly found in children 2 to 5. Its cure rate was 0 several decades ago, but with new treatments (including fetal stem cell transplants) runs from about 20% to 80% and tends to be closer to the high end in children her age. There are a number of factors involved, at least 5 variants of ALL have been isolated, and treatment can be expensive. Whew! At least the employee had insurance. However, a week earlier, the employee had made his first claims on his insurance company for preliminary testing which confirmed the presence of ALL. The insurance policy was just approaching its annual renewal point, and the insurance company, now aware of the child’s expensive disease, informed the CEO that they would not renew the policy if the employee continued to work there. HR frantically tried to find some other insurance company that would cover them, but was universally turned down. The CEO let the employee go reluctantly in order to keep insurance for his scores of other employees.

    The ex-employee was now jobless, couldn’t apply for unemployment insurance until at least one quarter of unemployment had passed (today in many states, it is 2 quarters), had been divorced the year before, and was a renter with no equity for a loan. He spent every penny he had, and his not-well-off family helped as much as they could. He couldn’t get his daughter into very successful clinical trials without insurance, and could not afford stem cell treatment. The insurance company did have a COBRA plan that would allow him to carry his insurance over by picking up the entire expense of it. However, the monthly payment was over $1,000, he had most of a $3,000 deductable to meet, the calendar year was close to over, which means his deductable would reset in a month. He couldn’t get any other, cheaper insurance, like an HMO, because, with a pre-existing condition, his daughter would have been exempted.

    There are three stages of treatment, remission induction, intensification, and maintenance. Normal treatment in remission induction is with a cocktail of anti-cancer drugs and, where warranted, bone marrow transplants. Some of the most effective, like Elspar, were not available as generics, and he simply couldn’t afford their price, let alone pay for surgical bone marrow transplants. His daughter received as much treatment as they could give here, but it was not enough, and, since leukemia is not a tumor, but cancerous cells spread throughout the body, she developed tumors in her spinal column and brain. Within weeks of his dismissal, his daughter was dead of a disease that, if he had retained his insurance, would have been perhaps 60 to 80% curable.

    If I seem to have a lot of knowledge about ALL, it is because my own 3-year-old niece had it recently, but was lucky enough to have the full panoply of treatment thanks to her family’s insurance plan and her father’s high earnings as an attorney. Now, she’s fine and, though she will carry some of the results of treatment side-effects for the rest of her life, has every reasonable expectation of living well into her 70s or beyond.

    The story of these two different little girls, and the tragic difference in the outcomes of identical diseases is one of the major reasons that I favor a single-payer system that would not deny care to a dying child just because it would impact their dividends to their investors.

    1. That is a tragic story, blue sun. I’m so sorry. It is sickening. This country. Why do we hate ourselves? I’m a patriot. I think every single American child is entitled to the best health care that anyone in the world gets. I cannot for the life of me understand how Republicans (or Brett) can think so much less of Americans than the Swiss (say) do of the Swiss.

    2. The insurance company did have a COBRA plan that would allow him to carry his insurance over by picking up the entire expense of it. However, the monthly payment was over $1,000…

      Which is about what ALL policies will cost under ObamaCare. (Seriously–COBRA is the closest proxy to what a guaranteed-issue policy costs if everyoen buys one.)

    3. Sob story fail. There are so many factual problems with this story I don’t know where to begin. THERE IS NO WAY IT IS TRUE.

      If your friend was covered under the company plan, he can’t be denied new coverage for pre-existing conditions. Even before pre-existing conditions were outlawed by the Affordable Care Act, you could not be denied from a new plan due to pre-existing conditions if you had insurance coverage within the prior 63 days. Most HMOs don’t have pre-ex anyway.

      All states have policy renewal guarantees. An insurance company by law can’t push one employee off of a plan. If they did, they would be asking for a major lawsuit (just in time to raise rates more). They can ask for premium increases, but these must be approved by the state insurance commissioners, and are usually capped at a certain percentage. Sounds like the CEO just didn’t want to pay for the increase.

      You can’t fire people due to medical conditions under federal law. Your buddy should sue his former employer if that’s why he got canned. (I bet there is more to the story of why he doesn’t work there)

      “The insurance company did have a COBRA plan…” Yes, because COBRA exists for all plans. Plans can charge up to 102% of the cost of the plan and you can keep this coverage for 18 months. If the employer really cared for the guy and somehow all of the above things really did happen, they could have kept him on staff and paid his COBRA. It would have been virtually a wash in cost for the company. It’s not Obamacare that is affecting these costs, it is what it actually costs to pay for people’s healthcare.

      Look, county hospitals are not the cure all, and making up stories to support your political agenda isn’t either. We have huge problems with obesity, lack of care for the poor, low use of preventative care, an amazing ability to spend lots of money and deliver mediocre results.

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