The Rest of the Story

Today I’m going to give you access to a paper with as many as 100 references that you almost never see cited in Health Affairs, or in the Journal of the American Medical Association (JAMA), or in the New England Journal (at least not in their public policy articles). In fact, if you are a regular reader of these publications, I think you are going to be very surprised.

My colleagues Linda Gorman, Devon Herrick, Robert Sade and I discovered that public policy articles in the leading health journals (especially the health policy journals) tend to cite poorly done studies over and over again in support of two propositions: (1) Our health care system needs radical reform and (2) the reform needs to be modeled along the lines of the systems of other developed countries. At the same time, these articles tend to ignore contravening studies – often published in economics journals and subject to much more rigorous peer review.


I can see clearly now

In our rest-of-the-story literature review, we focus on eight questions:

  1. Does the United States spend too much on health care?
  2. Are US outcomes no better and in some respects worse than those of other nations?
  3. Is the large number of uninsured in the US a crisis?
  4. Does lack of health insurance cause premature death?
  5. Are medical bills causing bankruptcy?
  6. Are administrative costs higher for private insurance than public insurance?
  7. Are low-income families more disadvantaged in the US system?
  8. Can the free market work in health care?

This paper was written over a year ago, in response to JAMA’s call for papers on health reform and may not include the most recent material. Nonetheless, since the national health care debate is well underway, since the peer review process (at least for our paper) is so inordinately long, and since the issue is so important, we are taking these unprecedented steps:

  1. We are ignoring the journals and publishing the paper online.
  2. We are posting the reviewers’ comments from Health Affairs so that readers can see why the critics thought this paper should not be published at all, and a link to the JAMA issue that excluded our paper here.
  3. We are inviting everyone – regardless of political views – to comment and cite additional evidence that has bearing on any of these questions.

In a completely independent effort, Stanford University Professor Scott Atlas has made many of these same discoveries. His findings are summarized in this NCPA Brief Analysis.

Comments (16)

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  1. Devon Herrick, National Center for Policy Analysis says:

    What is most shocking is how advocates of National Health Insurance ignore the poor state of cancer care in many developed countries. Cancer is primarily a disease of old age. Thus, rationing advanced cancer treatments should be considered a subtle form of age-discrimination.

    Other countries fare worse than the United States when it comes to cancer survival. Their data is somewhat dated but according to the report “Diffusion of Medicines in Europe,” there are only .14 oncologists per 100,000 population in Britain and .24 in Germany. The corresponding figure for the United States is 2.28. Innovative (cytotoxic) cancer medicines are also used much less abroad. The U.S. spends nearly 17 times more per capita that Britain, seven times more than Germany and five times more than France on cyctotoxic medicines.

  2. berga says:

    By Health Affairs purposefully ignoring valuable data that can only serve to strengthen the legitimacy of the national health care debate, they have misled the public, deliberately portraying an incomplete picture of health care. Furthermore, by excluding citations from rigorously peer-reviewed journals, Health Affairs also undermines its message of an informed debate.

    People need to have a complete picture of health care in America before damaging legislation is enforced.

  3. Brian R Williams says:

    “Ignorance is bliss” is not a good motto for journals like JAMA, NEJM or Health Affairs. As the nation begins to debate health reform, we need the most accurate and complete information possible.

  4. BowTieGuy says:

    Way to go! Bypassing a blatantly biased journal is the best way to keep the modern market for information moving. In the past, a few so-called “academics” like this could leverage their power and significantly retard the rate of that information made it to the public in an attempt to bolster their biases.

    Not anymore.

    Furthermore, besides being a good stand to take, it was a great idea for a paper and provides a solid foundation from which to argue as the health care reform debate picks up in Congress.

  5. Ronda says:

    Now, more than ever, we need to explore reform solutions, with a very careful eye toward what has –and has not — worked in other countries. Why limit our consideration of options? Why not learn from others’ experiences?

  6. George Beauchamp says:

    Thank you, John and colleagues, for this seminal contribution. “Health care”–with its notions about political, industrial, and financial models that net to a misguided emphasis on insurance as the end point of care–has overwhelmed the real problems we face in providing medical care to increasingly “entitled” American citizens. The more important agenda may be how to renew American medicine–the profession–and free it from the diversion of resources to processes and parties of tangential significance to the care of patients. Your paper opens a window to that possibility, by carefully examining the Emperor’s presumptive newly reformed clothes.

  7. Keith says:

    With minimal prompting, a college freshman econ major could tell you what’s wrong with Woolhandler and Himmelstein’s arguments about administrative costs. Yet, amazingly (actually I’m not so amazed anymore), “studies” like theirs continue to be published in respected journals like NEJM. And other people/groups (see this example from the AMA – are left to clean up the intellectual mess and explain to those journals’ readers (i.e. MDs with little econ knowledge, who will play an influential role in any health system reform) why the commonly-cited literature is rubbish.

    I (and I suspect many others) left the academic public health/policy world precisely because of the growing disconnect between rigorous, peer-reviewed research and advocacy/cheerleading research. I hope that John’s great work here is the first step in creating a way for us all to get back in.

  8. Roy Ramthun says:

    John, you are absolutely right. We are seeing the same bias in the “studies” of consumer-driven health care, most of which are based on theoretical discussions (i.e., consumers are too stupid to shop for better value in health care) or surveys of what people think about consumerism. Not one of them actually looks at claims data. Thanks for reminding us of the general bias we have to contend with.

  9. Jennie says:

    I’ve gotten excellent healthcare as long as I’ve had insurance. I’ve been allowed to pay off deductibles as long as I agreed to monthly payments. However, I think private health insurance companies tend to be greedy these days, and every year premiums and deductibles go up, while covered services go down. I don’t think they should pay their employees big bonuses every year for finding ways to deny health benefits! I have noticed though, that with the specter of publicly funded healthcare looming on the horizon a lot of these companies are starting to get more innovative and competitive with their products. I especially like the idea of portable health insurance rather than coverage offered by employers, which is actually getting scarce these days not to mention expensive and substandard. And really is publicly funded but privately delivered healthcare such a bad thing, as in HR676 which provides for expanded Medicare paid for by a 6% employer payroll tax (versus billions shelled out for employee “benefits”? What’s the difference between a government beaurocrat having a hand in deciding your health care needs, as opposed to some private insurance beaurocrat (after a bonus)trying to find a way to deny your health care needs to get that big end-of-year payout? Something to think about. There’s a spiraling cycle here of rising costs paid for by the insured to cover the uninsured, that is not going to get better as fewer employers offer benefits because they are just too expensive. Affordable individual policies would be welcome on the scene, but where are they?

  10. John Goodman says:

    A version of this post with additional comments may be found at The Health Affairs Blog:

  11. Dr William Pfeifer says:

    Don Nixford the author “Squandering Millions“ pointed out to me recently what many Americans don’t realize is that Canada does not have a National Health care program, plan or policy. They have provincial health care plans or policies where only a small amount of the health care costs are funded by the Canadian Government through a return of some National tax dollars and the balance is funded by the province (i.e. State) and those costs amount to 43% of the provincial budget and are expected to rise to 50% in the near future. We know our states couldn’t absorb such a cost.

    Dialog is the key to good policy, thanks for what both of you do in promoting thought and discussion.

  12. Jeff Trewhitt, spokesman, Pharmaceutical Research and Manufacturers of America says:

    Though the Pharmaceutical Research and Manufacturers of America (PhRMA) does support providing all Americans with access to affordable health insurance coverage with a focus on private health insurance expansions, we do believe reforms are necessary to prevent and better manage care for Americans who suffer from chronic diseases, promote healthy lifestyles and reduce health disparities among patients.

    The following lines from an op-ed by PhRMA President and CEO Billy Tauzin published by the Buffalo News March 12 help to explain what we think needs to be done:

    “Today in America, we have a sick-care system, not a health care system. Too many times we get to patients after they’ve been diagnosed or after their illness has already done serious damage.

    “One way to address this is by focusing on disease prevention and early intervention, with a particular focus on chronic disease.

    “Chronic diseases are the leading cause of death and a key driver of health care costs in the United States. Seventy-five percent of the nation’s health care spending goes toward taking care of patients with chronic disease. Lost workdays and lower employee productivity because of chronic diseases like cancer, diabetes and heart disease results in an annual economic loss in America of $1 trillion.

    “If Americans would stop smoking, improve their diets and exercise regularly, 80 percent of heart disease, stroke and type 2 diabetes sufferers wouldn’t need the health care they require today.

    “Prescription medicines play a critical role in preventing many chronic conditions. They can help avoid expensive hospitalizations and trips to the emergency room, thereby saving money.

    “For example, one study predicted that improving the use of blood pressure-lowering medicines would result in 89,000 fewer deaths and 420,000 fewer hospitalizations annually — a more than $15 billion a year reduction in health care costs.

    “Among health care services that are covered by insurance, prescription medicines get the least coverage. Even among Americans who have insurance, 14 million don’t have the kind of insurance that covers the prescription medicines they need.”

    As for improving the fight against chronic diseases, PhRMA makes a number of recommendations in its “Platform for a Healthy America,” including a reduction in obesity through a major public health campaign equal to the commitment and scale of the campaign that led to dramatic reductions in smoking, with a focus on early intervention targeted at schools and in the community. We also recommend support for comprehensive employer-sponsored wellness programs that engage employees to take charge of their health care and a new commission for improving care coordination and disease management for the millions of Americans who have chronic disease. The “Platform for a Healthy America” can be found on the Web site,

  13. Rodney W. Nichols says:


  14. Laura Estep Zeilmann RN says:

    As a registered nurse, I see the best and the worst of our healthcare system each and every day.

    One thing I know for sure is that we do NOT want a system like that which exists in Canada. One of our physician’s has a friend who lives in Canada. This friend needs a knee replacement. He has had to wait 5 months just to get in to see a surgeon. 5 MONTHS! This man endured excrutiating pain for months on end, all thanks to Canada’s healthcare system. And he is still waiting for surgery. Who knows how long that wait will be?

    I also see doctors ordering unecessary tests every day, with the idea of “covering their butt” because we have such a sue-happy society. What a waste of money this is.

    It is heartbreaking when a patient does get diagnosed with a chronic illness, and we send them home with new prescriptions. I’ve been told by patients that they can’t afford their medicines so often lately that it is just sad. It isn’t right that our senior citizens are forced to choose between paying their rent or buying their needed medications.

    I agree completely that what we now have is a “sick care” system. If our healthcare system could shift to a more proactive focus, we would be able detect problems at an earlier stage, manage the condition more effictively, and as a result save money down the road. But insurance companies won’t support proactive screenings in many cases. You have to be sick in order for it to qualify as “reasonable and necessary”.

    Thought should be given to taking the bulk of the decision-making process away from the insurance companies & giving it back to the physicians & other healthcare professionals. The insurance companies run the show, and it isn’t right. The clinicians know what is best for the patients, NOT some stuffed suit sitting in an office somewhere who is only concerned about his profit margin, and not the actual patients.

  15. Dr. Tracy says:


  16. Larry Foster says:

    Thank you very much. I’m always amazed at what politicians keep saying: that the health care system we have is the best health care system in the world, and yet it is not perfect. They don’t take in consideration that we are going to have thousands and thousands of doctors that are going to be retiring in the next few years and especially because they are sick and tired that they have to put up with government interference. They also do not encourage their children to go into medicine. There’s gonna be an incredible shortage of physicians in the future. It looks like to me that someone should do a survey and find out what the average costs per patient per day is presently just to keep up with the government paperwork. Like the old saying goes, if you think it’s expensive mail wait till it’s free. The other thing that we must realize: when people get sick or hurt they don’t go out and get bids to fix the problem. We keep hearing about the uninsured — there are many, many people that wouldn’t buy it if you gave it to all. If they have to make a decision between car insurance and health insurers they will take the car insurance overtime. In fact, our laws require them to have car insurance. If you can name one thing that the government does better than private industry please let me know what it is. My premiums for my health insurance are reasonable now that I am of the age where I have to use it so much. I wish there was a way that I could continue to pay my premiums and never ever have to use it. The biggest improvement that I would like to see is for the physicians to have a better way of communicating with each other about what’s going on between the general practice physician, the cardiologist, the urologist and the ent physician.

    John, you are appreciated for what you’re trying to accomplish.