The 3Cs

The Economist has an interesting article on how Japan has been able to largely contain COVID-19. Part of the success has been a strong public health initiatives around avoiding the san-mitsu, or the “3Cs”. The 3Cs to avoid are: Closed spaces, Crowded places, and Close-contact settings.

The phrase was blasted across traditional and social media. Surveys conducted in the spring found that a big majority were avoiding 3C settings. The publishing house Jiyukokuminsha recently declared in “buzzword of the year” for 2020.

Cases are rising, however,. According to Johns Hopkins, with Japan hitting it’s all-time high of COVID cases and deaths this month. However, these numbers are from a much lower base and are still just 1-2 percent of the number of cases and deaths the US is currently experiencing.

With rising COVID-19 cases around the world, and especially here in California, it is important for everyone to take action to stay safe during these holidays.

Healthcare spending by age: An international comparison

We all know that health care spending per person in the US is highest among all countries. But are these results consistent across age groups? That is the question posed by Papanicolas et al. (2020). Using 2015 OECD data from the US and 7 other high-income countries (i.e., Australia, Canada, Germany, Japan, the Netherlands, Switzerland, and the United Kingdom), the authors find the following:

In the US, per capita health care spending was $9524, or 1.9-fold higher than the mean for the 7 comparator countries….The absolute difference between US spending and that of the other countries for ages 0 to 4 years was $3899, and that difference decreased at approximately age 5 years, after which it slowly increased. The difference increased faster after age 65 years, peaking at $18 645 for ages 80 to 84 years.

Papanicolas et al. (2020)

In short, health care spending in the US is higher across basically all ages.

Health care battle: US vs. England

A new study by Choi et al. (2020) compares the health of individuals aged 55-64 in the US compared to England. They use data from Health and Retirement Study (HRS)–in the US–and the English Longitudinal Study of Ageing (ELSA) for 2008-2016. Health is measured across 16 outcomes: 5 self-assessed outcomes, 3 directly measured outcomes, and the prevalence of 8 key comorbidties. They find:

Cross-country differences in health were in favor of England for all health outcomes except ADL limitations, depression, and measured blood pressure, which were not significantly different between countries.

Of perhaps more interest is that they compare health outcomes among individuals in the top compared to bottom income deciles across countries. In this analysis, they find:

Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis.

The authors do note that these differences persist even after statistically controlling for demographic factors, educational level, smoking, and body mass index. Note that the outcomes are relatively crude measures and the data cover only individuals aged 55 to 64. Further, the study describe what these differences are, but not they why of why these occur. Nevertheless, these results do provide a helpful snapshot comparing the health of Americans and the English across income strata.

Health care in Ukraine

Recently I read an interesting book called Moneyland by Oliver Bullough. The book describes how with porous borders facilitated by the internet, the rich can evade taxes, hide assets, and basically pick and choose the international legal system most favorable to their interests.

One interesting part of the book discusses health care in the Ukraine and how it has evolved over time. I am not an expert in the Ukrainian health care system so this was interesting to read. Of note is that although health care is free in Ukraine’s socialized system, it really isn’t free.

Ukraine’s constitution guaranteed free healthcare, but in reality patients paid for almost everything. Supposedly, the institutes budget was adequate for all of its needs, but doctors’ salaries were tiny and they were forced to ask patients to fund their own drugs, or even to contribute money towards the upkeep of equipment.

So socialized medicine did not appear to be working well here. The author notes that the Ukrainian kleptocratic government stole funds from healthcare which helped exacerbate the underfunding. If you are a fan of private health insurance, you would say that government corruption and inefficiencies are rife in publicly funded systems so this is no surprise. If you favor socialized medicine, you would say that countries with good governance and stronger institutions than Ukraine could solve these problems and that private health insurance is not without its own problems.

The author compares the current Ukrainian health care system to the system under Soviet times and does so with a bit of rose-tinted glasses.

In Soviet times…the government under-valued doctors who were paid little. Ordinary citizens, however, were grateful to the medics that helped them get better and brought them presents: candy, or alcohol…If you went to the doctor, even though healthcare was free, you took something along to give her. After 1991 when the Soviet Union collapsed, the situation changed, however. Doctors began to realize how much their Western colleagues were earning and also to appreciate the heft of their position…

‘When we were a market economy, sweets or brandy didn’t cut it anymore,’ the agent said. ‘Doctors wanted money, actual banknotes, and people started paying them…

Ukrainian health care costs are socialized, in that the government pays for the facilities,
the buildings and the infrastructure. The profits, however, are privatized, in that the doctors get to keep what they earn.

To read between the lines, doctors have been underpaid consistently under socialized medicine and bribes have been a endemic in their system over many decades. The author, however, naively believes that in Soviet times “They weren’t so much bribes as genuine gifts” whereas under capitalism the bribes were bribes. Let’s call a spade a spade; when there is no market clearing price and queues form, bribes may occur to get closer to a market-clearing price.

General comments on the book

Despite my write-up, above, most of the book is about the ability to move assets offshore to avoid government taxes and regulation. Overall, the book is interesting, but a bit long and would be better served as a long essay. Few people care to learn about so many of the the different ways the rich can flaunt the laws. Further, the book focuses on bad people avoiding good laws. In practice, however, sometimes dictatorships will confiscate moneys outside the rule of law. In this case, good people with means may use Moneyland to hide their assets from the kleptocracy. Often, in fact, the kleptocrats themselves are hiding their assets offshore.

In short, the book is interesting and worth a read, but I put it down half way through after I largely got the gist of the author’s key points.