Wednesday, July 20, 2011

The Price is...ummm....errrr.... Wrong (Part 2)

Many moons ago, while at university, I had a dog - a cross between a Chow-Chow and an Alsatian (the snout, eyes and dimension of the chow, with the shorter fur, muscularity, ears, and demeanor of the shepherd). Chow, as he was called, (named by a housemate at his moment of maximum apathy) had an iron constitution cultivated through years of his solo carousing, particularly his late night visits to the back of the local pizzeria, and his rummaging of the neighborhood's rubbish bins. When not on the prowl, Chow spent most of his time on our gently-sloping 4x3 meter first floor front roof - "guarding" his errr ummm....castle.  He was an odd a sight - such that he became a bit of a local celebrity, and a well-loved local fixture. So, when I looked out the window and saw he'd vomited his (and our) dinner of the "freshly" caught and grilled bluefish fillets that "friends" had brought as proof of their fishing exploits,  I suspected that I, too, might soon meet a similar fate.

Food poisoning is NOT fun. Food poisoning that results from bad fish can be unspeakably horrible. Leaving out the most gruesome bits, I found myself the next scorcher-of-a-July morning with a fever rallying like the price of Silver after a bubble-vision interview with Jim Rogers, or the Bunker-Hunt's declaration that they were in possession of most of the Comex warehouse receipts. I experienced a cycle of chills and sweats such that when my then GF who was worried by my moans and climbing fever, took me to a private clinic nearby (the only one open on a Sunday morning), I left the house wrapped in blanket despite the triple-digit [fahrenheit] temperature. Not exaggerating, I was unable to sit upright in the chair in the waiting room such were the shivers and vertiginous undulations. As my friend dispensed formalities with the clerk-nurse, so I laid myself on the floor of the empty waiting room. "How would you like to pay?" queried the bespectacled overweight nurse-cum-bouncer in the most deadpan of tones. "Errrr, can't we do this after?" my friend said, "I mean, look at him (pointing to me on the floor) he's, like, pretty bad". Receptionist replied (expressionless again) as if she was uttering the most normal thing in the world: "No, you cannot see the doctor until you have paid." "I'll write her a check", I managed between groans, having followed the conversation between the near- hallucinations (the kind that makes one maniacal about Ayn Rand as described in Tobias Wolff's"Old School"), the chills and the somersaulting of the waiting room. Nurse-Bouncer return-volleyed: "I am sorry, we don't take personal checks". "WTF....WTFFingF.....@%$!! Was all I could utter, though it is unclear how comprehensible it was, if audible at all. Suffice to say, this was Sunday, mid-day, in the low-rent 'burbs, before cell-phones, before the internet, before ubiquitous ATMs, before debit cards, and at a time when credit cards were hardly inventory in the typical undergraduate student's billfold. So I lay there, shivering as if I were atop the Eiger in January, despite the 100F heat and mid-summer humidity outside. Fortunately, payment was sorted out by a phone-call to GFs mother who was kind enough to send eldest sister down with funds. Welcome to the American Healthcare System!, I cursed afterwards.  In hindsight, I should have gone to the hospital, but at THAT time, our belief was that The Hospital (with upper-case "H") was reserved for CRITICAL things - a limb being sewn back on it's owner, brain surgery, C-section births, removing buckshot from Dick Cheney's ass, gunshot and/or stab wounds and the like. I still shake my head and ask whether it really happened, but it did - just as described.

Time-leap nearly three decades forward. Eldest daughter recently had a heart scare during athletics, in the UK. Nothing critical, but something unknown which begged investigation. The attending GP suggested that she see a specialist. By nature of her residence, she's covered by the NHS. Rationing queue meant the earliest appointment was six weeks. However, if she wanted to jump the queue, the specialist will see her privately immediately. Cost? GBP800. That is just for the consultation - presumably (though not assuredly) including the ECG & stress test(s). Rather than be pick-pocketed by over-enterprising UK cardiologist, we are able to get an appointment at a private practice near our home in France (BTW, contrary to popular belief in the US and the UK, all practices in France are private) in two weeks coinciding with her next visit home. She undergoes a thorough exam, stress tests and ECG. Useful but inconclusive. Cost? GBP100. (Note: That is not the co-payment. That is the invoiced amount!!). In the absence of seeing her when another episode might arises, he recommends an MRI (with hi-tech contrast media etc.) to rule out the worst. We make an appointment (also at a private clinic) for two-days hence. Tests are completed. New machines. Super high-tech gear. Cost? GBP125, inclusive of radiographer's reading and opinion. This is, again, NOT the co-pay (in US lingo), but the private price to the customer. This is the usual and customary cost reimbursed by the State Single Payer. They extend the same price to me without question, so I don't have to be Kaiser Permanente to obtain their volume discount. Each visit type or procedure has a price. That is that. Full transparency. Not one price for the insurance company and the other "retail walk-in's". One price.  One of my children had a small tongue-tie clipped at a suburban New York hospital. The anaesthesiologist alone charged $800 (and that was 10 years ago) for the 10-minutes and two-jokes (not including the cost of the anaesthetic itself), while the full procedure was $6000 (retail, walk-in, rack-rate price).  In France they do this as an outpatient procedure in the ENT surgeon's office with a local anaesthetic, for less than a twentieth of the price.  I can only imagine what my daughter's same two cardiological and radiological consultations and procedures would have cost in the US (but would be fascinated whether anyone knows the range of prices one might encounter).

The troubling thing to an Economist (or me at least, lest I shame Economists if such a thing were possible), is the sheer discrepancy between these actual prices. These are factors of 6x between the private UK price and private French price (even before the USA weighs in). We are not talking about a hospital in India where the reward for saving 75% on your procedure is an untreatable staphylococcus infection that might very-well kill you.  Remember, the French cardiologists and radiologists are private. They are running businesses. They are free to charge what they want. Their equipment is not subsidized, so presumably the fees per scan and payback periods of their MRI scanner must make some economic sense. This is not Greece or Portugal sovereign, and French banks are notoriously hard-nosed with domestic small business customers who get their sums wrong (unlike the lax scrutiny they gave to Europe's peripheral sovereigns. Admittedly, prices in the 16th of Paris would be somewhat higher, but nonetheless my region is one of the wealthiest in France. So one might ask, Why is this so?

Well for a start, French doctors and specialists are probably underpaid. But they are not starving, though they are clearly bearing some of the difference, particularly GPs and Dentists. Why don't they just charge more? Well, for one, most people wouldn't pay or couldn't pay, and would seek out the provider charging the usual and customary reimbursed by the Single Payor. France also has a single nationwide healthcare IT system interfacing with all providers which is a huge advantage, both from a cost and ability to track fraud point of view. And the The Single Payor has the entire risk pool, which prevents the state from getting all the expensive chronic conditions, and the private sector cherry-picking the good risk, and privatizing (i.e. pocketing most or the majority of the fatter underwriting profit), and so not passing it on the insured person, or the state who is the ultimate underwriter. And of course the State does get the chronic conditions. And happily so, because  its all well and good for Libertarians to say this is "unfair" to the healthy or the young, who are paying more than they actuarily should (in isolation), except one never knows when or who chronic will strike, and it could be YOU. Americans have never grasped this democratic fact, sufficiently to make generational sharing a priority. The concept of a "pre-existing condition" doesn't exist in France. The insured cost IS socialized, by design (and efficiently so!) and for the overwhelming majority (excepting those with private planes), everyone is better off.  There is NO ONE in the French Healthcare civil service earning anywhere close to what directors and senior officers at private US HMOs, Health Insurers, and Hospital Groups extract from patients, corporate customers, taxpayers and shareholders.  By an unimaginably huge factor. No one (least of all the CEOs, Directors, and managers of the French Healthcare infrastructure) has suggested that the French State "Demutualize", as they did in the US (driven by the lure of exceptional parochial gain.  Even the Private providers of French "Top-Up" Health Insurance are dominated by private but non-profit mutuals.  The largesse of corporate health insurance hierarchies are not reproduced over-and-over so that there are fewer pigs at the trough extracting for their private benefit, every healthcare dollar they can seize, which is the apparent SOP in the USA. The French run a utilitarian ship, without having their board meetings in exotic places, or the award of share options for doing what they are paid to do: their job. And it shows. Perhaps it's too utilitarian, but it is clear (unless you are in the business of surgically extracting dollars from the various constituents) which side the public-as-financier and benefactor should err on. 

Does this make the French stupid for not more aggressively taking advantage of extraction opportunities? What by implication does this say about the USA? France spends approximately 12% of GDP for which citizens receive universal coverage, better outcomes, full choice of providers, total portability, no rationing, and most important perhaps, no exclusions. This is more spending than the UK NHS's 9% but 7% of GDP LESS than the USA's fragmented, byzantine system, so weird and absurd that you couldn't design it as such, or replicate it if you tried. That is 7% of $14 trillion GDP or the equivalent of spending approximately a trillion dollars  (yes $1,000,000,000,000) LESS and achieving SUBSTANTIALLY MORE. Because this is a rather important point, it bears repeating again (and again!). Universal coverage (i.e., yes,  Everyone); Complete Freedom of Choice (you can visit any doctor you choose); Prescription Meds covered with nominal co-pays.  NO EXCLUSIONS FOR PRE-EXISTING CONDITIONS (one never knows who may afflicted next, defeating the entire purpose of "insurance"). Complete portability (i.e.. no worries when you change jobs or if get fired). Reimbursement for alternative therapies (Naturopathy, acupuncture, prevention, etc.), latest technology in more or less similar proportions as the US, and separate extended-coverage insurance offered by the private market to pay for private rooms, vision care, top specialists, fashion eyewear, travel health insurance, etc. -  all for 7% of GDP LESS spend than the USA. Medicare-like "insurance", that primarily pays  the bills of Gran's third hip replacement, Pap's coronary roto-rootering or by-pass, or daily Lipitor ration, but doesn't level the cost across the risk-pool over one's life-cycle can hardly be called insurance, but rather are just direct transfer payments under the guise of "insurance". France, by contrast, levies social security taxes upon all (attenuated by ability to pay), set at something which equates to one's share of the expenditure across the whole population. There are shortfalls to be certain, but these are measured in numbers with zeros that remain tethered to reality and bridgeable. Everyone who can must contribute by law according to a strict schedule, for which in return, citizens are legally entitled to coverage. It is a crackingly good, fair, not to mention pragmatic approach to the problem.  

Yet, champions of the US system will still claim its "better", and are afraid of losing what they have. When my father was diagnosed with lung-cancer, his Health insurance company refused to pay for the Tarceva prescribed by his attending cancer specialist. Tarceva is VERY expensive. And admittedly, it is for most, rarely a cure. Yet the specialist, (at the Ivy teaching hospital) who was one of the top specialists in the field of the type of cancer he was treating, prescribed the medicine and was told by the insurance company that they will not pay. The prescription was based upon the patient's cancer's likely sensitivity to the compound. THAT is the much-vaunted  US Healthcare system: rife with conflicts of interest; maximum extraction, no transparency, little logic that is not parochially self-serving. When I went to my local pharmacy (here in France) and explained  my father's situation to my friendly pharmacist, she just couldn't understand, and looked at me as if I was from Mars. It was inconceivable to her. In her world, if the doctor is licensed, he is presumed to know best.  The Single-payor is obliged to pay for the procedures and medicines the doctor prescribes. No questions (unless there is fraud or ethical situation). Apologists for US Healthcare Byzantium will point out the possibility of fraud and abuse. Let it be said: there is abuse and fraud. But is remains the exception rather than the rule, and even with abuse and fraud included they still spend only 12% of GDP on Healthcare. Yes ~12% vs. US ~19%.

But perhaps, the French are just be Healthier?. The outcome statistics could be masking what are essentially lifestyle and societal differences: better diet, more exercise, less processed food, universal coverage that encourages preventive care and early detection that, in a virtuous circle, lower costs. But the French smoke like chimneys and drink alcohol like camels at an oasis after a Sahara crossing. They eat food that often is more fat than anything else (for breakfast, lunch, and dinner). And obesity is rising rapidly here too. But they do eat better (more fresh veg, and lots of fresh fruit). They eat seasonally. Their coffees are measured by the thimble, they they have more of them, while the concept of the Big Gulp, and Supersize meals, meet with amusement and derision, despite the growing popularity of Starbucks and ubiquity of McDonalds. To be sure the reasons are numerous, and while a factor, lifestyle while important, is probably not dominant.

It is surprising that France has not become a destination for healthcare tourists. It is surprising that in the UK, there is no middle ground between public and private healthcare such that one's NHS benefit is not applied to one's private visit. But it is more surprising (and alarming) that socialized medicine (a misnomer if ever there was one when applied to France) is met with derision by most, and that America doesn't look to emulate the better organized healthcare systems in developed nations around the globe.  Sure there are dedicated professionals who should be lauded. But they exist elsewhere too. I look in earnest for the virtues of the American healthcare system, and they are systemically absent, save my old highly-competent NYC dentist who charged a very reasonable rate for my visits - so long as it was in cash. A Saint? An altruist? Nope, just four ex-wives with a claim on every reported depreciating dollar....      

18 comments:

Anonymous said...

Hi Cassandra,

It has long been my contention that until the US gets serious about healthcare (& defence) we should take and efforts at reform with a pinch of salt. I think people are starting to wake up, I have included charts on this for years in macro presentations to fixed income investors which were always received with polite silence - recently people show interest; perhaps the whole Iraq debacle has tarnished the myth of US efficiency for global investors.

Sorry to hear of your experiences with the NHS. I recently had a blackout and was given an MRI & ECG (& a whole load of other stuff) really quickly seeing three different consultants in the process (turned out I've just overclocked my brain - need to calm down a bit). Admittedly my local hospital is St Thomas' right opposite parliament so probably gets the best budget.

Most developed countries get what they pay for (The UK is cheap) apart from the US. I would love to see the variances broken down as I am at a loss to understand how so large a difference (US healthcare staff are paid more but not that much more) can exist.

Hope all is well

Cheers

Tim

PS comments google log-in not working properly

An expat said...

Cassandra,

Your article is spot on in about every respect that I know about, after living here in France for much of the last 30 years.

Now I have survivor's guilt.

Anonymous said...

Hello,

I'm an American currently living in Taiwan. Of course the Taiwanese health care system is much more efficient and effective than the American healthcare system. The Taiwanese system is that there is a single health insurance company which happens to be owned by the government (and whenever the insurance company tries to raise premiums and/or co-payments, Taiwanese votes raise hell, so the managers have a strong incentive to control costs and keep prices low). Almost all private practices accept the insurance reimbursements (they wouldn't get many patients if they didn't), though the government also runs a number of health care facilities directly. While I haven't had any major medical problems while in Taiwan, I was pleased with how the healthcare system handled the medical issues I did have, and I loved the low out-of-pocket costs even more. Everyone (at least in the urban areas) can access and afford decent medical care.

One of the things I dread most about my return to the United States is the return to the broken health care system.

-MK

Anonymous said...

We had a similar experience where my wife was stung by a bee and we went to the emergency room in France. No wait. Pleasant. Wound dressed, doctor met and prescription provided. Exemplary service let alone care.

And then the bill. One price. $54.

For the love of pete they have the better way. We are so broken and stupid not to demand similarly.

Vive la difference and hopefully we'll look to see how to save a TRILLION as we are broke!

OUR SYSTEM IS AMORAL. IT is one of greed. The private sector dumps on the hospitals who become primary care providers for those who can't afford insurance.

Madness. Sheer Madness and we cannot afford this.

Anonymous said...

I'd just add the *much* lower administrative costs and overheads of the French system.

As to the lower income of medical professionals compared to the US - it is not very hard to live well in France on the incomes they do receive (maybe not exorbitant, but fine by local standards). So most will be reasonably satisfied.

Anonymous said...

Considering stress is not exactly healthy either, maybe some of the better outcomes of the French system are simply due to the absence of medical-finance related worries in patients?

David Pearson said...

Great post! My daughter had an ear infection during a vacation in a small Provence town a few years back. It was nighttime, and we called a number for medical attention included in the rental villa's info packet. Forty five minutes later, a quite capable, if a tiny bit tipsy, doctor arrived at our villa. He examined the ear, wrote a prescription, and then spend a half hour chatting with us, in Italian, about his travels through Latin America. From us, French health care gets wild applause.

Nevertheless, I wonder if the French have lower costs due to less end-of-life care? As a society, I'm not sure Americans would accept this trade off.

Anonymous said...

Great exposition! I'm Canadian, and a believer in our style of social(ized/ist) health care, but it was very illuminating to read your description of a high-functioning private system. Thanks.

BTW Tim's right about "defence" factoring in here. It continues to be a source of wonder and elevated blood pressure to me that the US government can casually tear through hundreds of billions pursuing wars only the private-plane set were ever in favour of, while sacking domestic infrastructure and "entitlements" (yeesh - that word) with the gusto of a tribe of Vandals on acid. And it's all treated as politics as usual...

(Posted anonymously because Tim said the Google login was down. My name's Andrew.)

Anonymous said...

Another story on the absurdity of the US healthcare system (I'm an American living in the US):
I get annual blood testing done by mail order. I pay $26 for a lipid panel (cholesterol counts, etc.). There's no lab in my city so I go to a local hospital to have the blood drawn and send the blood sample to the lab by overnight delivery service (the $26 includes the cost of shipping, btw). The hospital charges about $20 for the blood draw. One year, the hospital made a mistake and billed me for the blood test instead of just the blood draw. When I alerted them to their mistake, they corrected it, but I was shocked that they charge over $600 for the blood text, roughly 25x what I pay to the mail-order provider.

"Cassandra" said...

Thanks for all the comments. The things is, the anecdotes from experience are nearly endless. I was in the US when my middle child got a case of red-eye. Not a bad one, but irritating and not fun. It is simple to treat with antibiotic drops. But try, as a "foreigner" in the US with no address, and no GP, to get a scrip, or coax a sample treatment cycle from the the automaton's in the pharmacies (CVS, Walgreen's). Impossible. And we're not talking Vicodin here, but vampire-eyed 8 year-old in obvious need of some medication. In France, for many simple maladies, many people go to the pharmacy FIRST, where the pharmacists often own their own pharmacy and still have knowledge lost from the robots who (in the US and UK) take pills from a large bottle and slap them into small bottle with a label mfgr-provided crib sheet. I have rarely in my two decades in and out of France, not seen pharmacists exercise discretion and judgment to dispense medicines irrespective of a doctor's prescription. Of course one wouldn't get reimbursed without a doctor's prescription but in situations of urgency, outside doctor's hours, such discretion is valuable to the whole system. Interestingly, French pharmacists are experts in other things where they also obliged to identify all mushrooms to distinguish the edible from the dangerous.

But we digress from the issue of price, which was my point. A huge problem in the US is the cost (and timeliness) of tests. The corporatization of testing has seemingly created oligopolies where the supposedly efficient market diagnostic companies seemingly compete with the internal hospital labs to charge the highest price most divorced from reality. Here again, one doesn't know what they charge UNH or Kaiser, but the cost is the same. SO why should there be two (or in fact more!!) prices with the price for the walk-in bearing no relation to the real price, or the internal hospital price subsidizing all manner things unrelated to COGS. Laboratories in France are ubiquitious, and efficient and test costs are always measured in the double-digits - never (or rarely) triple. The costs are known before, and transparency is full. They are private, mostly independently owned, turn a profit and are present in nearly every market-town. And the fact that there is a single-payer who - cutting the bullshit - almost unilaterally imposes the reimbursement prices upon providers, doesn't seem to affect provider supply in the least, quite to the contrary to US libertarian and lobbyist fear-mongering. The same is true of doctors. It has never been harder to get into medical school in France (just as it is in the US and UK), only the French medical students KNOW they are not likely to earn what Bridalplasty or Dr90210 practitioners garner.

I am embarrassed when I visit my GP. She charges Euro22 per visit. That is still more (on an hourly basis than my plumber or electrician - but not by much). My co-pay alone in my old fee-for-service plan (in a country that used Canadian usual& customary) was MORE than that, and the insurer reimbursed the GP an additional $70. Both probably saw 4 or 5 patients an hour though I would be surprised if my GP here can do 6 or 7. My children's old GP just built what one could only call a mansion on a piece of land that itself cost a decade of a French GPs total GROSS income. And he doesn't make house-calls whereas our GP here was at our home within a few hours when my spouse couldn't get out of bed due to a serious case of vertigo.

"Cassandra" said...

(con't)

I keep looking for something nice to say about US healthcare. I guess they managed to do a good job shrinking my father's Stage IV lung cancer tumors to a manageable level (at a staggeringly high insurable monetary cost), but probably killed my mother by sloppily removing a mass that should have been biopsied toute-suite and removed by an expert, causing the malignant growth to metastisize. Subsequent doctors offering palliative care were under a seeming omerta when it came to establishing "blame", but if we pursued a malpractice case - we would of course only be making things worse, and in any event wouldn't bring her back.

Again, these are anecdotes. The facts remain: US spends 19% of GDP for byzantine chaotic partial coverage system with flaws large enough for the moon to pass through, where as an essentially private system of providers bounded by a single-payer as equal guardian of patient rights and tax-payer interests expends 12% for universal coverage and - in comparison to the US - relatively minor systemic flaws.

I pity the poor libertarian who is horribly conflicted in trying to weigh up the free-market negative of a single payer, versus the powerful virtue of the same single-payer (however bureaucratic and inefficient according to their dogma) helping to save nearly 7% of GDP on behalf of the taxpayers. Michelle Bachman and Tea-Party-ers....over to you....

hipparchia said...

you're absolutely right about the prices, and they're low in part because doctors agreed to them in exchange for the govt [insurer] NOT telling them how to practice medicine:

French national health insurance allows for free choice of providers and clinical autonomy of physicians even more so than in the United States. French physicians are never asked to play gatekeeper functions and are not subject to the kind of utilization review and quality assurance bureaucracy that has transformed the working lives of American doctors. But this freedom has at least two consequences. First, for patients, direct payment for most ambulatory care, the growth of extra-billing, and out-of-pocket payments amounting to almost one-fifth of personal health care expenditures are the quid pro quo for universal national health insurance with no restrictions on patient-demanded services. Second, in exchange for more clinical autonomy than American providers now enjoy and a national health insurance system with universal coverage, French physicians and other providers have learned to live with lower prices and lower incomes than their American counterparts receive.

http://www.nyu.edu/projects/rodwin/french.html

updated version, by the same author:

http://ajph.aphapublications.org/cgi/reprint/93/1/31.pdf

kabunushi said...

fwiw, you probably know Cass, but japan also is super reasonable even for the uninsured and much cheaper for the insured with cost of insurance very cheap. dental is also super cheap.

last year i was visiting as a tourist. went to a hospital's outpatient clinic during normal hours in loud pain on every breath. i had cracked/broken 3-5 ribs and had suddenly gotten much worse after 3 days. have family history of pulmonary embolism and personal history of blood clots.

they rushed me right in to the exam room, gave me iv fluids and iv pain meds, oxygen, an ekg, chest xrays (2 sets, one for possible clot, one for details on broken ribs). Was seen by 2 docs, one for emergency diag to rule out blood clot in the lungs, one to diagnose the broken ribs. total bill was $700. it might have been cheaper than other hospitals because it was a nat health hospital, but i paid a non-insured price which i guess is between 1/15 and 1/10 what i'd be billed by any US ER as an uninsured.

Antipodeus said...

Hi Cassandra,
Came here via 'Naked Capitalism: Links'. Very interesting article, & comments. As an Australian, I can also vouch for the virtues of 'socialized medicine'. I believe Yves Smith ('Ms. Naked Capitalism') had some experience of it during her stay with us, and some nice comments on its efficacy.

Question: I've been looking for 'The Price is...ummm....errrr.... Wrong (Part 1)' and can't seem to find it, if there is one. Can you provide a link?

Thanks & regards ... James

"Cassandra" said...

James, Part 1 was actually called Limey Beans, but it contemplated another wrong price, chiefly the CHF.

Hipparchia: thanks for the background on the "entente cordiale" between providers and insurance. Interestingly, the French are way of ahead of Americans in the idea of 'education portability'. The fairness idea being that one pays tax `(or would if one could), and with this comes rights to the benefit which is the amount of funding earmarked per pupil which is credited to whichever school - state or private or just the friendly one without the alcoholic or bitch-tyrant Director/Directrice - one wishes their children to attend. Unlike the US or UK where one forfeits one's rights when choosing a private or school in another locale. But my point, (again providing a bipolar conundrum for conservatives and libertarians) is that like the pact granting de facto independence of service providers in exchange for the public good of cost containment, is mirrored in education. The State will fund the private (mostly, but not all, catholic) schools, but in exchange demands such schools follow the official curriculum. This insures that - even in the private catholic school (where my son attends) there is no chance of creationism or other wacky doctrines being taught. It is essentially "vouchers with strings". In the US, somewhat queerly (no pun intended) the conservative voucher champions are demanding all the rights with none of the responsibilities. But would they tinker with the idea of relinquishing the exclusionary benefit of schools being funded from local property taxes used as an economic barrier in order to keep the immigrants and the poor from tainting the purity of Pleasantville? Methinks not....

Kabunushi - That is the order of magnitude that scares the shit out non-US insurers providing coverage that MIGHT include travel or living in the USA. Not North America, but solely the USA. It is a standard question-section and separate insurable option for US coverage. American exceptionalism indeed!!

Anonymous said...

.
Australia has a pretty decent setup
basic free public and private insurance for comfort ,
one of the big private insurer is in fact government owned

more to the point , if one take travel insurance , the cost for cover in the U.S is nearly double than for the rest of the OCDE countries ,

....Jeannick

Oliver said...

Agree on the good cost/quality ratio of many continental healthcare systems...

Yet, in many respects, the French system you describe is freer than the UK one (an absolute catastrophe in my personal experience). So, there is a degree of centralization/socialization past which the attractiveness of the system severely trends down. This is mirrored elsewhere - the freewheeling Belgian system tends to make happier patient than the heavily regulated Dutch one. Thus, empirically, you have to find a compromise between Aynd Rand and "the State does everything" mentality, not artificially trash one.

Criticizing the US system just on this basis sounds wrong to me - for example what about the role of the Tort Bar (one of the un-Ayn Rand Democrats most steadfast supporters) in making medical insurance premium so high?

Last point: now that national debt explodes and population ages, I think it is not a time for Europeans to gloat. We will have to see where we land in 10 years.

foster-boondoggle said...

Oliver - The evidence on the contribution of tort costs to care in the US puts it at around 2% of total healthcare spending. That's nowhere near enough to account for the difference between US and other western countries' costs.

The US system is extremely unlikely to change for the better barring some major shock (and I can't imagine what that might be). Reasons: (1) Industry capture of the legislature. The beneficiaries of the US system (the providers, hospitals and drug co's) can radically outspend anyone trying to limit their profits. (2) "American Exceptionalism". For a large and vocal segment of the populace, the idea that anyone anywhere could be doing anything that we could learn from is abhorrent. "America is best" is a manra to be repeated loudly and often so as to drown out any evidence to the contrary.