Tag Archives: USA

Our Failed Health-care System

The bad idea behind our failed health-care system by Malcolm Gladwell

One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system.

Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193; the extra spending comes to hundreds of billions of dollars a year. What does that extra spending buy us? Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average.

Health Savings Accounts represent the final, irrevocable step in the actuarial direction. If you are preoccupied with moral hazard, then you want people to pay for care with their own money, and, when you do that, the sick inevitably end up paying more than the healthy. And when you make people choose an insurance plan that fits their individual needs, those with significant medical problems will choose expensive health plans that cover lots of things, while those with few health problems will choose cheaper, bare-bones plans.

In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.

This is another article with an interesting take on the problems with the broken health care system in the USA. I don’t totally agree with the conclusion. I think the failure of the system and refusal to make substantial change have multiple causes including: smart lobbyists paying politicians lots of money to support their interest in keeping the current system, people being fearful about change, false perceptions about the system performance (thankfully an understanding of the poor performance is becoming more widespread recently), that the system works least poorly for the wealthy who have more influence than those without insurance, that the benefits of spending huge amounts today are going to specific companies and people and thus are available for buying political support (not just paying politicians but also funding marketing campaigns, experts to provide journalists the position of those in favor of the existing system…) while the benefits of changing are much more distributed. Luckily companies are increasingly – decades after Deming noted this health care costs are a huge problem for companies in the USA – focusing on the need for improving what is often one of the largest expenses for companies. The issue many fail to understand is how much the excessive costs of health care in the USA harm the ability of companies in the USA to compete – many even fail to appreciate the human cost of tens of millions of people without health insurance.

Related: Drug Prices in the USAMeasuring the Health of NationsOverview of 5 Nations Health Care SystemsFixing Health CareImproving the Health Care System

Outsourcing To America

Outsourcing To America

Toyota (TM) began operating in North America in the mid-1980s. It currently operates seven automotive plants there, four of which are in the U.S. A fifth plant is under production in Mississippi. Toyota employs 40,000 manufacturing employees in North America.

In addition to the manufacture of cars and trucks, Toyota runs four unit factories in the U.S., where they produce such parts as engines, transmissions and wheels. Toyota also has a wholly owned subsidiary, Bodine Aluminum, an aluminum casting company, which operates three factories in Tennessee and Missouri.

BMW began operations in the U.S. in 1994, when it opened a plant in Spartanburg, S.C. “Some natural hedging was always a part of the long-term strategy, but also we have a corporate strategy of having production follow the market,” says Robert Hitt, BMW’s manager of public affairs. “Our original plan was to have about 2,000 workers here by the year 2000. We are now at 5,400 people here on the site.”

Besides the actual manufacturing of their cars and trucks, Toyota and BMW are using domestic suppliers to provide parts and services for their operations. BMW has over 200 suppliers in North America, 52 of which are located in South Carolina, and 41 of these are new companies started for the purpose of supplying the plant. In South Carolina alone, suppliers of BMW’s Spartanburg plant employ over 14,000 people.

Toyota uses roughly 500 major suppliers in North America. “We’ve always had the philosophy that we should build vehicles where they are sold, so it makes sense to have suppliers close to your manufacturing operations,” says Mike Goss, external affairs manager for Toyota’s engineering and manufacturing division in North America.

Foreign production in the U.S., however, is not limited to the automotive industry…. In fact, almost 1 million Americans get their paychecks from Mexican companies, says Ton Heijmen, senior adviser for outsourcing and offshoring for the Conference Board.

Related: Top 10 Manufacturing Countries 2006Moving Jobs to Silicon Valley from IndiaGlobal Manufacturing Jobs DataToyota in the United States of America EconomyChina Outsourcing Manufacturing to USA

Measuring the Health of Nations

Measuring the Health of Nations: Updating an Earlier Analysis

In a Commonwealth Fund-supported study comparing preventable deaths in 19 industrialized countries, researchers found that the United States placed last. While the other nations improved dramatically between the two study periods (1997–98 and 2002–03) the U.S. improved only slightly on the measure.

Rankings: 1) France 2) Japan 3) Australia 4) Spain 5) Italy 6) Canada… 18) Portugal 19) USA. Maybe the United States is last but still not significantly behind?

According to the authors, if the U.S. had been able reduce amenable mortality to the average rate achieved by the three top-performing countries, there would have been 101,000 fewer deaths annually by the end of the study period.

It might seem like a stretch to compare the lowest ranked country to the average of the top 3, but, for all those that feel the USA is the best health care system it raises the questions of why they don’t think 100,000 annual deaths is a significant enough problem to lower their opinion of the current system. And remember the USA system costs something like twice as much as the average system: up to 16% of GNP in 2006.

I must say I would rather have the Toyota mindset shown by those talking about the USA health system instead of the claims of how the current USA health system is number 1. In Toyota’s horrible last year they still had a profit of about $14 billion (I believe something like 20 companies have every made that much). The United States health system sure has some things to point to positively but the system seems to be losing ground to the rest of the world more and more quickly while many cling to a belief it is the best system around.

Related: Evidence-based Managementposts on improving health careImproving Hospital Performancearticles on improvement health careBest Research University RankingsTop 10 Manufacturing CountriesDr. Deming’s Seven Deadly Diseases of Western Management

Top 10 Manufacturing Countries

The newest data from the UN* confirms most of the recent trends in manufacturing output – most notably that China continues to grow dramatically. The data also shows a stagnation in USA manufacturing output over the last several years, though the USA remains by far the largest manufacturer. The most significant news from this latest data, I believe, is that that manufacturing output growth in the USA has been slower than global manufacturing output growth from 2002-2005. This was not the case prior to 2002. I will be writing more on this data in the Curious Cat Investing and Economics Blog. UN Data, in billions of current US dollars:

Country 1990 1995 2000 2001 2002 2003 2004 2005
USA 1,040 1,289 1,543 1,460 1,471 1,488 1,545 1,493
Japan 809 1,217 1,033 857 807 886 962 964
China 143 299 484 527 573 664 788 895
Germany 437 517 392 389 407 490 566 594
United Kingdom 207 221 230 218 222 239 283 no data
Italy 240 226 206 205 218 259 295 291
France 200 233 190 185 192 228 256 253
Korea 200 233 190 185 192 228 256 253
Canada 92 100 129 119 120 149 170 196
Brazil 117 149 120 102 95 109 130 171
Spain 108 107 98 100 108 134 153 160
Mexico 50 55 107 110 111 104 111 122
Russia 201 104 73 77 54 64 92 117
India 50 60 67 68 72 84 100 116

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USA Healthcare Costs Now 16% of GDP

U.S. Health Spending Estimates [the broken link was removed]:

Health care spending growth in the United States slowed for the third consecutive year in 2005, increasing 6.9 percent compared to 7.2 percent growth in 2004 and 8.1 percent in 2003, the Centers for Medicare & Medicaid services (CMS) reported today.

The 6.9 percent growth in 2005 marks the slowest rate of growth in health spending since 1999, when growth was 6.2 percent. Health care spending reached almost $2.0 trillion in 2005, or $6,697 per person, up from $6,322 per person in 2004.

So the rate at which healthcare spending continues to increase is decreasing. That is better than increasing at an increasing rate. However, it is already a huge drag on the economy and the need is for the expenditures to actually decrease (not slow down the rate of increase) and for performance to improve. There are good things being done but much more is needed. Health care costs are a huge cost for companies.

Health Care Spending in the United States and OECD Countries [the broken link was removed]

This growing gap between health spending in the U.S. and that of other developed countries may encourage policymakers to look more closely at what people in the U.S. are getting for their far higher and faster growing spending on health care.

Related: USA Health Care Costs reach 15.3% of GDP – the highest percentage ever (2 years ago)Health care spending rose at twice the rate of inflation in ’05Health Care Costs Approach $2 Trillion – Bill takes on prescription costs [the broken link was removed]

China’s Manufacturing Economy

Brad Setser posts on manufacturing comparisons: Have China’s manufacturing powers been exaggerated? [the broken link was removed]

I am all for pushing against over-generalizations that get repeated so often that they become conventional wisdom. The oft-stated argument that France isn’t growing is one example. In fact, France has grown faster than either Germany or Italy over the past few years, and France grew for the same reason the US grew: soaring real estate prices have pumped up domestic demand.

But I would submit that the real story here is the growth in China’s conventional wisdom to improve our understanding of the real situation. I agree with him that the growth in China’s manufacturing sector is the most important story.

But, to me, that story is so over-reported that many get the wrong impression. The constant mention of the eroding manufacturing sector on the USA I believe leads many to think it is shrinking and small. Yet output continues to increase and the share of worldwide manufacturing output is holding steady. China is gaining substantial ground but the Chinese increase has largely come from Japan and Europe. To me this understanding is important because of my felling about the misperceptions of many. But this is nothing more than my judgement.

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Toyota Production System in Indiana

photo in a Toyota plant
Photo by Daniel R. Patmore

Via Evolving Excellence [the broken link was removed], Indiana plant president passes on lessons (newspaper broke link so I removed it):

Q. Is it different teaching the Toyota Production System to American team members than it is to teach it to Japanese?

A. It’s not so different. Americans are eager to learn. American team members are more serious about job security, so their motivation is higher than that of the Japanese.

The Japanese are more obedient to the boss. Americans show more individual initiative. Once they understand why we have to continue kaizen, we get a much better result than you’d expect.

Q. What are the biggest misconceptions about the Toyota Production System?

A. Sometimes it’s misunderstood as a management tool to bring cost down. Or that it’s effective even if only a portion of TPS is introduced, such as kanban. (Kanban is inventory replenishment.) That’s not the Toyota Production System.

Kanban is easy to introduce as a logistics system, but its purpose is not to reduce logistics costs. It’s a tool to bring problems to the surface. Not many people understand that. As we reduce inventory, all problems come to the surface, and that way you solve problems and your system gets stronger.

Manufacturing and the Economy

In Global Market, Iowa Manufacturers Fight for Survival:

The conventional wisdom has been that expanded trade would result in the United States losing low-pay, low-skilled manufacturing jobs, said David Swenson, an economic scientist at Iowa State University. But “a lot of the jobs that we have traditionally thought of as high value, high quality, high benefits are in trouble, too.”

The conventional wisdom was that the rest of the world would not be able to compete with the United States for high wage, high value jobs. It turns out the rest of the world is much more able to compete for that work than was expected.
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USA Health Care Costs reach 15.3% of GDP – the highest percentage ever

re: Health Care Spending In The United States Slows For The First Time In Seven Years

The Centers for Medicare and Medicaid Services (part of the United States Department of Health and Human Services) issued a report (the press release states that report will appear in the Jan/Feb edition of Health Affairs but does not provide a link so the link is my guess of where the report will appear) and a news release putting a positive spin on the data.

“Spending growth for prescription drugs decelerated significantly to 10.7 percent, down from 14.9 percent in 2002.” So we only increased spending on prescription drugs by 10.7 percent? I guess that could be seen as positive? To me though increasing expenditures by 10.2 percent seems more like of a problem than a success, though I can’t argue it is less of a problem than the year before. My last post was on prescription drug prices in the USA.
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Economics – America and China

Business Week has several good articles on the topic of China’s Economic impact including: Shaking up Trade Theory and The China Price.

In Shaking up Trade Theory Aaron Bernstein explores: “The fact that programming, engineering, and other high-skilled jobs are jumping to places such as China and India seems to conflict head-on with the 200-year-old doctrine of comparative advantage.” Over the last few years the white collar job losses in tech US have seemed to cause quite a bit more concern than the manufacturing and other job losses of the 1980s and 1990s. His article does a good job of exploring this issue within the limits of a short magazine article.

He captures the surprise economist (in the US) see because “Conversely, India, where just a fraction of its 400 million-plus workers have gone to college, should grab the low-skilled work and leave higher-end products to the U.S.” That conflicts with the data that many high skilled jobs are going to India (and elsewhere). The US Economists don’t seem to realize India is producing as many college educated engineers as the US. So India also has hundreds of millions of low skill workers that doesn’t mean they don’t also have plenty of high skilled worked (that speak English, which is, of course a huge benefit that is less true of Chinese high skilled workers).

Ok, I need to do better research but here is one source: “I know that US production of engineers declined from about 80K (in ’85) to about 65K – but is back up to about 75K in the latest data. For context, however, the production of engineers is over 200,000/yr in each of China and India.” Wm. A. Wulf, President, National Academy of Engineering (United States) in talk entitled: Out-sourcing/Off-shoring of Engineering Jobs.Update: see USA Under-counting Engineering Graduates
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