What annoys me as an American about our health care is not that some other countries achieve better outcomes at much lower cost--it is that they do so in so many different ways.
For instance, if they all did it by having the government completely run the health care system, with all doctors working for government hospitals and clinics, and being trained in government medical schools, with all costs set by the government, then I could understand the US rejecting that as being too much government intrusion. (Note I didn't say I'd necessarily agree with such rejection--good health care arguably is more important than limited government power--I'm just saying I could understand such rejection).
But looking around, what stands out is how diverse the approaches of other countries are. There are some that do have the government finance and provide health care, much the way the police or military are provided by the government.
There are some that use private insurers paying, with care provided by private hospitals and doctors, but the insurance companies are non-profit and regulated.
There are some that provide care via private hospitals and doctors, but have a government run insurance program to pay for it.
See also the link on that page to the explanation of the four basic models used around the world. That page includes a striking way to explain the other systems to Americans:
These four models should be fairly easy for Americans to
understand because we have elements of all of them in our
fragmented national health care apparatus. When it comes
to treating veterans, we're Britain or Cuba. For Americans
over the age of 65 on Medicare, we're Canada. For working
Americans who get insurance on the job, we're Germany.
For the 15 percent of the population who have no health
insurance, the United States is Cambodia or Burkina Faso
or rural India, with access to a doctor available if you
can pay the bill out-of-pocket at the time of treatment
or if you're sick enough to be admitted to the emergency
ward at the public hospital.
This kind of problem seems fairly widespread in America. Americans are incredibly self-confident, innovative and have achieved a great deal as a nation. They are also extremely proud of their country.
Unfortunately this combination often leads them to assume things are good purely because they are American. They tend to accept their own familiar values and ideas and readily dismiss alternatives because that would be admitting failure. As a result you get incredibly conservative attitudes in some areas side-by-side with world leading innovation in another.
A major driver of U.S. costs that isn't discussed in the article is our parasite lawyer class, who drive up the cost of insurance for doctors and lead to widespread over-testing or "defensive medicine". Few Americans are proud of our litigious society.
Malpractice suits are about 2% of healthcare costs, and that percentage is stable, so you're not going to make a huge difference by focusing efforts there. Tort reform is a diversion, not a solution.
Malpractice suits are about 2% of healthcare costs, and that percentage is stable, so you're not going to make a huge difference by focusing efforts there.
The cost to avoid lawsuits adds up with a lot of tests that are not needed. Doctors end up doing whole batteries of tests on everyone to avoid the 1:1000 or higher chance that the person in their office with a headache really had an aneurysm and get the doctor sued for negligence when he sends them home.
Another side effect of all these tests is that many are extremely dangerous. CT scans in particular are ordered way too often and can does people with levels of radiation that lead to problems later in life.
I have anecdotal evidence to back up these claims: my mother is in internal medicine and my father is a surgeon. both have practiced defensive medicine and my father has complained about how common an occurrence it is on a regular basis.
Many tests, drugs and treatments have been applied in the name of defensive medicine.
The followup question is, how much defensive medicine is necessary? If there's a 5% drop in that practice then do the costs from lawsuits go up to compensate? Are we at an equilibrium point, or are doctors doing defensive medicine because the myth of the power of a lawsuit is so strong?
I am a physician, and I teach in a medical school. Although they are 2% of total costs, they drive up the cost in unnecessary procedures that patients demand without medical indication. Those $1080 MRIs are often ordered to avoid a lawsuit. That adds up to a lot more than 2%.
I'm a doc based in the UK. I know that we order fewer useless investigations than you do in the US. Thankfully we don't have a litigation heavy medical culture yet. Although, I think it's slowly heading that way.
My dad is a surgeon, so that's my appeal to authority and anecdote. In my country litigation isn't a problem, but unnecessary treatment is. People go doctor shopping to find one that gives them the treatment they want. Same problem, different cause.
As I understand it now, doctors have largely invested in testing companies. When they (not all doctors obviously) - I probably thinking primary doctors - order tests the test is a money maker for the doctor.
Wouldn't a calculation of the effect of litigation include the scenario you mentioned? Otherwise it would seem to be a bad calculation. Do you have any studies that show how often a test is ordered simply to avoid a lawsuit?
The second link hardly endorses your view. It says
Although our estimates delineate a wide range of potential savings, systemwide savings from aggressive malpractice reform could approach $41 billion over five years.
According to one source [1] the U.S. spent $2.6 trillion in health care in 2010. An $8 - $9 billion dollar savings per year from eliminating defensive medicine hardly adds up to "a lot more than 2%".
I agree that the second link is saying more about the effects from malpractice reform. I have seen the Kaiser study, and what I think they are not taking into account is the culture of defensive medicine that may physicians don't even think about. For example, an MRI is more likely in a US Emergency Room than in a UK Emergency Room. UK practice is (in general) evidence based, and they won't order it unless it makes sense to do so. May US physicians would not identify this as "defensive" because the practice is so widespread, although the root reason for ordering it stems from that cause. I am not aware of an analysis that takes this into account.
I only read the abstracts, so correct me if I'm wrong, but both of those links fail to compare the US with other countries. I.e they don't show that costs in America are higher than other countries due to defensive medicine. It could be that all countries have higher costs due to defensive medicine, we wouldn't know from these studies.
Yeah but 2% of a very high cost is higher than it would be if the cost is lower (obviously). Of course you won't cut the costs much by targeting those 2% at first, but if you ever get to reasonable prices those 2% would transform in 7% and 7% is starting to be notable.
Regarding the so-called "parasite lawyer class", you might be interested in reading "Blocking the Courthouse Door: How the Republican Party and Its Corporate Allies Are Taking Away Your Right to Sue"[1]
From a Booklist review of the book:
By demonizing trial attorneys and exaggerating high-profile litigation
awards -- the famous McDonald's hot-coffee case -- campaigns for limiting
damage awards threaten to jeopardize the American right to civil jury
trials guaranteed by the Bill of Rights. Investigative reporter Mencimer
examines the Republican campaigns for tort reform that would protect
large corporations from "frivolous lawsuits." The campaigns carry the
dual benefit of supporting the interests of corporations that are major
Republican campaign contributors and hurting trial lawyers, who are part
of the contribution base of Democrats. Mencimer criticizes the media for
their lack of understanding about civil litigation, willingness to
swallow reports of litigation abuses, and failure to understand that
Republican tort reform will also limit the ability of news organizations
to sue for information. Drawing on national data and scrutiny of
individual cases, Mencimer defends the civil justice system and its
reliance on jurors, average citizens who are the same people who vote.
This is an eye-opening look at an important issue for readers concerned
with the civil justice system.
also, "The Lawyer Myth: A Defense of the American Legal Profession"[2]
From the Booklist review:
However disliked lawyers have become, they have played an essential role
in the development of the American democracy, assert legal scholars
Strickland and Read. Taking aim at media critics -- left and right -- who
blame lawyers for a host of social ills, Strickland and Read debunk
several popular myths about lawyers. They begin with the notion that
there are too many lawyers and lawsuits, citing statistics to put things
into perspective, and they point to the benefits that have come from
lawsuits, including increased consumer protection from faulty products.
But they concede the need for reform in a chapter that calls for major
research into alternative legal mechanisms. Finally, Strickland and Read
look toward the next generation of lawyers and outline the
characteristics most essential for the practice of law: competency,
responsiveness, and integrity. They emphasize that it’s not what lawyers
bring to the law but what they give that makes a difference. This book
is not likely to stop lawyer jokes, but it is an insightful look at a
much-maligned profession.
I believe there to be a more concrete cause of US healthcare costs: collusion between insurance companies and healthcare providers. "Insurance" includes both health insurance and malpractice insurance, as well as "providers" being hospitals/doctors and manufacturers of equipment and drugs.
I think what all of these countries have in common is that they have a strong entity negotiating prices on behalf of the patients, drastically lowering the price, and to a varying degrees also dictating what treatment is appropriate.
It'd be really nice if health care could work like a regular market, but evidence and intuition suggest it simply doesn't. As others have commented, people don't comparison shop even if they could. It's a bit like having no idea how a car works or what could be wrong with it, and then being asked to pick the best mechanic and strategy to fix it. Except of course, that it's not a car but your life or somebody else's depending on the right choice. I think it's unrealistic to expect a working market economy to develop under such circumstances.
One or multiple big entities negotiating prices and dictating treatment comes at the cost of less freedom for the providers and also less freedom for the consumers. Whether it gives better or worse care I wouldn't be too sure - on the one hand, special cases won't get specialised treatment, on the other hand trusting the decision of what needs to be done effectively to the provider sounds like it will cause over-treatment.
The freedom aspect probably drives the USA to the current system, but given the measurable effects, it just seems like bad policy.
I think what all of these countries have in common is that they have a strong entity negotiating prices on behalf of the patients, drastically lowering the price, and to a varying degrees also dictating what treatment is appropriate.
The US has these entities too - they are called "insurance companies".
As others have commented, people don't comparison shop even if they could.
This is simply false. People with low deductible insurance don't comparison shop because they have no incentive to do so. I have no insurance (my startup is minimally funded), and I do comparison shop.
It's a bit like having no idea how a car works or what could be wrong with it, and then being asked to pick the best mechanic and strategy to fix it.
Here is what I did a few weeks back. I went to a doctor who ordered an MRI. I called around, discovered the price of MRI's varied from 5-7k (INR, not USD), and then picked the closest one to my home (the price difference was small enough that I didn't care).
When it came time to get treatment, I did research on the internet, as well as asking three separate doctors. They all independently had the same recommendation - microlumbar discectomy on L5-S1. This was fairly apparent based also on the pattern of pain I was suffering, and just by looking at the MRI. I ruled out one hospital because it seemed dirty, chose a doctor/hospital to have it done (not the cheapest, but not the priciest), downgraded from a deluxe room to a private one [1], and got myself fixed up.
This doesn't work for emergency medicine, but most medicine is not emergencies.
[1] The default over here is to give white guys the gold-plated options.
Do you have evidence that you are normative in terms of comparison shopping for healthcare? It seems to me that costs won't vary much between providers and that comparison shopping would be a mostly useless thing to do in the U.S. Indeed, your own experience in comparison shopping is that the price differential was not that great.
Health insurers in the U.S. have a captive audience. Most people before the age of 60 who have insurance get it through their employer. What the employer pays for insurance comes out of money that would be paid in salary. It seems to me that the insurance companies don't have a great incentive to lower cost of healthcare. On the surface the evidence suggests that they haven't since procedures cost so much more here than elsewhere.
I don't live in the US, but India does have a health care system fairly similar to the US. The biggest difference is it has less red tape than the US, and insurance companies play a minor role. Most people pay out of pocket and comparison shop.
Costs here did vary significantly for the surgery - the dirty hospital was 0.9-1.5lac (depending on general ward vs private room, etc), the place where I had it done was about 85k. It was the MRI for which the price differential was minor.
I was actually pretty surprised that the price gap was so big - I wouldn't have expected the city hospital to be almost 2x as much as the private hospital.
It seems to me that the insurance companies don't have a great incentive to lower cost of healthcare.
Insurance companies don't have a great incentive to lower the cost of their biggest expense? Um, ok.
On the surface the evidence suggests that they haven't since procedures cost so much more here than elsewhere.
The relevant counterfactual is what procedures would cost absent insurance company negotiation, not what they would cost if US patients had as few MRI's as French patients and US health care workers were paid as little as their French counterparts.
I'm not so much glossing it over as emphasizing it. The Indian healthcare system is like the US healthcare system, except people are not insulated from the price. As a result, people shop around.
I.e., Nitramp is wrong, people are capable of shopping around, all they need is incentive to do so.
And then ignoring most of the others, like the truly colossal difference in money spent per capita and the fact that the public health system, while so chronically underfunded that it is unable to do it's job, is at least nominally charged with trying to provide a free universal service paid for by taxation.
Insurance companies don't have a great incentive to lower the cost of their biggest expense? Um, ok.
They only have such incentive if it increases their profit margins. There are a number of scenarios where this wouldn't be the case. They aren't interested in lowering cost just for the sake of lowering cost. I don't have data either way and so my belief in this is easily shaken.
I'm confused, could you name a situation in which this wouldn't be the case? The profits that an insurance company makes are the amount it charges for its services minus the amount that it pays out, it seems that reducing the amount they pay out would necessarily increase profits.
I'm not aware of any insurance companies that charge on a cost-plus basis, and the insurance companies can't just charge companies as much as they want (or else they'd charge an infinite amount).
One situation: if they believe that their competitors will follow suit. Unless an insurance company concocts a way to lower costs that isn't easily replicable, they have little incentive to do so. Otherwise, they're just triggering a race to the bottom.
By this logic, no company in any industry should attempt to reduce costs in an easily replicable way. Since the world doesn't behave that way, there must be something wrong with your logic.
Or maybe there's nothing wrong with my logic. Maybe there are other forces at play that, when all mixed together, result in companies sometimes seeking cost reductions, and sometimes not seeking cost reductions.
Parent was looking for an example to explain a possible situation, not a dynamic that the entire world must obey at all times.
> The US has these entities too - they are called "insurance companies".
As mentioned in the article, American insurance companies appear not to be very good at negotiating prices, partly because the providers are permitted to negotiate different prices with different companies, and to treat these negotiated prices as trade secrets. This is a highly unusual state of affairs.
So you are saying that US insurance companies are dramatically lowering the prices.
If so, then compared to what exactly?
The US has some of the highest costs per treatment of just about anywhere in the world, so if the insurance companies are dramatically lowering prices, then the only conclusion I can draw is that the US healthcare providers must be powering all their equipment by burning money for fuel or something.
The premiums set by American insurance companies will be largely driven by the cost of the services they provide. If they get providers to lower costs, then insurance premiums will decrease across the board, both for that company and their competitors. They can negotiate small discounts in their own individual favor, but large measures that truly cut costs and not just prices will impact everyone. As such, there's no real reason for insurance companies to negotiate for lower costs, since competition will ensure that their premiums decrease by a similar amount and they don't make any more money. Since demand for health care is pretty inelastic, they won't gain substantially more custom by lowering prices, thus they have no reason to try to substantially cut costs..
They are certainly lowering the prices, hence the constant back and forth (literally for 30 years straight) of local market consolidation between the buyers (health insurers) and the suppliers (hospitals/physicians). There are legal fights going on all over the country because of all the pricing issues; Pittsburgh is a great example of how the dominant insurer (Highmark) simply refused to pay the dominant provider's (UPMC) price increase. Highmark's solution? Vertical integration and just buy the other local health system.
In terms of MRIs, you have some odd effects with pricing, particularly when the MRI is seated inside of a massive tertiary care center instead of a standalone facility. If you look at the pricing discrepancies, it is almost always related to getting the MRI done at an academic medical center versus one of the ambulatory care centers. The problem is actually pretty simple: hospitals are terrible at cost accounting and totally game it. Instead of taking the leasing costs over the expected uses of the machine, adding in time for the technician and a bit of a real estate or facility charge, they allocate hospital costs (from all departments/overhead) to services based on their expectations on what they can charge. Michael Porter and his staff at HBS are looking at this right now.
Further complicating MRIs (I'm not sure if this is included in the study's cost estimate) is that radiologists essentially operate in a cartel fashion. They are rarely, if ever, employed by the hospital (like most doctors), but band together and set outrageous prices for reading images. Radiology, despite being non-patient facing and limited liability (they render opinions to other doctors, not patients), is one of the most lucrative medical trades. Eventually, traditional radiology should give way - either through disruption (overseas or computers) or by other doctors simply saying why the heck should a radiologist get money for reading an image I can read myself and will then have to intervene on anyways?
Startups have emerged in price/transparency space (e.g. Castlight Health) and will hopefully start to put pressure on hospitals/physicians to actually compete with one another and bring down costs. Since they have so much local market power, there is only so far an insurer can go without owning an entire market.
>The problem is actually pretty simple: hospitals are terrible at cost accounting and totally game it.
It's not that they're terrible at cost accounting. The problem is the hospitals are required to provide care to people who can't pay, particularly in the ER and obstetrics. So costs are shifted from other departments to pay for these services.
That's why people who are trying to hold down costs by zeroing in on this test or that procedure are destined to fail. Somehow the service the hospital is required to provide without reimbursement will have to be paid for, either explicitly or through the sort of sleight-of-hand accounting we see today.
This is very true. It was actually the argument that convinced me that a public provided healthcare system (at least for preventative treatment) is an awesome idea.
So if they have been lowering prices for 30 years, why do the prices keep going up?
I know there are increased costs due to medical advances, but this only accounts for half the increase in costs according to studies, so the rise from 5% of GDP in the 60's to 16% of GDP today, especially seeing the massive increase in GDP during that period, does not chime at all with the idea that the insurance industry is lowering prices in any meaningful way.
In fact, any rational observer might well assume exactly the opposite.
My comment should have said that absent insurers over that time period, prices would be higher than they are currently. The effect they have is on controlling the level of price increases, not on lowering price absolutely (which I doubt is possible if people wish to keep extending their lives).
I am not saying that insurers are the most effective option or advocating for them; I am only saying that without them, prices would be significantly higher.
If you need evidence, simply compare the total price of any health care service (i.e. total cash outlay by all parties) between a person who carries health insurance and a person who does not. Universally, the price of the service is higher for the uninsured as they lack negotiating power.
We have had such comparisons for MRIs posted on this thread already, given as examples of prices being much less at facilities that do not deal with insurers at all.
While I would agree that having buying power should bring down prices, this can be completely outweighed by the middleman trying to maximise profits. If prices are kept high, for instance, then you can make more money per person, so therefore having less administrative overhead per dollar made and so more profit margin.
For a non-medical example of this, just have a look at Apple, who make tons more money than their competitors, despite shifting less product, by simply ignoring the bottom end of the market.
> good health care arguably is more important than limited government power
Of course, even that only applies if increasing government power will even improve healthcare (in the long and/or short run), and if increasing government power won't have ancillary negative effects that counter the improvement in healthcare.
Don't forget that in Canada it's illegal to be a private medic. Medical services are ostensibly free, but rationed through queues. If you have a medical condition that's not immediately threatening, you may find yourself waiting for years for treatment, or have to go across the border to buy it.
That's not correct. There are private clinics who essentially claim the costs of their services from the government as though they were an insurance company. Costs that can't be recouped in full are passed on to the consumer or insurance providers, or you can be referred to a public hospital where the same service may be provided for free.
As for waiting times, you may find yourself waiting for years but it's highly unlikely. The median time for surgery in Canada is 4 weeks.
As a Canadian, the stuff that I see other people telling _me_ about my healthcare system makes me upset.
As others have said, it's not illegal to be private in Canada.
Everyone who seeks medical attention at a hospital is sent through triage, you are right. If you don't have a life threatening problem you won't be treated first, but saying "sometimes people wait a years for treatment" is just hilariously misleading.
Canada has a public health insurance program. Medical services are privately provided except for hospitals which usually are partially government subsidized on top of the health fees due to the high capital costs of building them.
That's not a requirement of such a system, though; France has a dual public/private system, where everyone is guaranteed service at the public system, but well-off people who wish to pay extra can purchase private care.
That's true of the UK system too. People get public treatment, but can go private if they wish. There are some restrictions on novel cancer medications if those are shown to be both expensive and minimally effective. I don't know if it's a good thing that dying people are protected from high pressure selling of pharmaceutical companies or whether the government should just allow people to spend tens of thousands of pounds on medication that may not extend their life and may not improve (and may decrease) their quality of life for the remaining weeks they have.
I've used VA health care. It is awful. AWFUL. Let me explain using an analogy. What do you think the quality of care would be like if doctors could not be held accountable for their actions in a meaningful way?
It's not difficult to figure out what happens to a marketplace when you remove the competition with government mandate. America's health care system has been hyper regulated for decades. You can't even shop across state lines effectively.
We have the worst of both systems. We have enough government interference to drive up prices through restriction of competition, bad regulation, bad mandates; and we have government sponsored 'private' entities there to capture the high prices from the stagnant and controlled markets.
Of course, all of the countries with good health care have more regulation, not less. (Yes, even in Switzerland.) Do you know of any countries with minimal health care regulations and good outcomes? I suspect they don't exist, because the preconditions of a functioning free market do not exist for health care consumption (rational consumers, symmetry of information, consumer choice, etc.)
Of course, all of the countries with good health care have more regulation, not less.
All you've identified is that rich nations have good health care regardless of how much regulation they have. This is hardly surprising - the evidence suggests that once health care exceeds a certain minimum level, it has little effect on health outcomes.
Incidentally, the Indian health care system is excellent and less regulated than the US one. I'm very lucky that I blew out my back in over here rather than in the US. I didn't come over here as a medical tourist (my startup is in Pune), but I strongly recommend that more people consider it.
Granted, the vast majority of people here are too poor to use the health care system effectively, but that's not the fault of the system.
"the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket"
Although it dovetails with the well worn narrative on HN, this comparison fails due to the level of care.
Also, from the article comments:
"There are just a couple problems. In 2009, the French Society of Radiology equipment in France was critically undermining care, and the government was refusing to increase capacity, even though people at many emergency rooms couldn't get an MRI even if they needed one because the equipment simply wasn't available. So, yes, the French government has held down the price of MRIs in France...by not purchasing enough MRI machines that one is available at every hospital. If you need an MRI in France, you're rolling the dice that you would be able to get one in a timely fashion.
Second, some of the development of MRI technology happened in Britain. Most was performed in the U.S. Who is paying for the cost of development of this and other new technology and drugs? It's often not the people in places like Canada and France, where government controls hold down prices. Most of the cost of research and development is paid for by Americans. We pay perhaps five times more in the U.S. for some procedures than people in France pay, but the technology might not exist in the first place if we didn't pay this disproportionate share. Once the technology exists, companies keep charging as much as they can in the U.S. to recoup costs and to fund development of the next big thing in medicine, and meanwhile other countries in the world adopt the technology, gaining benefits from it without actually paying the costs. This is Canada, France, and much of Europe. Plenty of medical research goes on in these countries, but American consumers ultimately bear most of the cost. It's an unfair system in many respects, but it's what has kept medical research moving ahead for the last several decades."
> Although it dovetails with the well worn narrative on HN, this comparison fails due to the level of care.
The context is purely the model of provision; level of care isn't addressed.
> Second, some of the development of MRI technology happened in Britain. Most was performed in the U.S. Who is paying for the cost of development of this and other new technology and drugs? It's often not the people in places like Canada and France, where government controls hold down prices. Most of the cost of research and development is paid for by Americans. We pay perhaps five times more in the U.S. for some procedures than people in France pay, but the technology might not exist in the first place if we didn't pay this disproportionate share.
This is an interesting point, in that much of the technology is actually developed outside the US, but the very high prices which Americans pay may be funding some of the development. That said, drug companies, for instance, only spend in the region of 12% on research, less than they spend on marketing. This marketing spend is disproportionately targeted at the US, as it's one of the few countries which permits heavy marketing of prescription drugs directly to normal people.
"This marketing spend is disproportionately targeted at the US, as it's one of the few countries which permits heavy marketing of prescription drugs directly to normal people."
By few, you mean two, soon to be one. The US and New Zealand, and New Zealand has passed legislation to phase it out.
The US will be the only country in the world where you can be advised of your potential need for a prescription drug not by a medical professional, but by an actor on a television screen.
In a way this can happen (though i'm far from being sure it actually does...): the medical area is one where the prices are the most regulated. In the public sector the prices for an MRI are probably very largely fixed by the government (and more probably completely) and given that even in the private sector you need an authorization to build an MRI counting them mean the medium price will not increase too much and the public operators might have less arguments to ask the government for price increase. Of course that would maybe not destroy effects of offers and demand and I don't know which one would win in the long term. But remember that health is a very different market than commodities and trying to compare the economics of health vs. crews and bolts by using crews and bolts theory might not going to work well.
The lack of MRI is a big problem in France anyway. Regardless of the effect on prices (except maybe if they triple or something like that) having 100% more would be a lot better.
For instance, if they all did it by having the government completely run the health care system, with all doctors working for government hospitals and clinics, and being trained in government medical schools, with all costs set by the government, then I could understand the US rejecting that as being too much government intrusion. (Note I didn't say I'd necessarily agree with such rejection--good health care arguably is more important than limited government power--I'm just saying I could understand such rejection).
But looking around, what stands out is how diverse the approaches of other countries are. There are some that do have the government finance and provide health care, much the way the police or military are provided by the government.
There are some that use private insurers paying, with care provided by private hospitals and doctors, but the insurance companies are non-profit and regulated.
There are some that provide care via private hospitals and doctors, but have a government run insurance program to pay for it.
There was a good look at how it is done in 5 capitalist democracies here: http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/c...
See also the link on that page to the explanation of the four basic models used around the world. That page includes a striking way to explain the other systems to Americans: