(cough)

Not terribly surprising, given the coverage of foreign health care in the US media (and not just in Reason Magazine, for that matter). I think it’s just a general article of faith among most Americans who haven’t lived abroad that even if our health care system is a godawful mess, the extant alternatives are far worse. Completely wrongheaded, but where are there any voices saying otherwise?

Anytime the New York Times (to take one example) publishes anything at all about health care in France, you can be sure that one of 2 templates will be followed: (1) horrible service, waiting lists, filthy hospitals, bureaucracy, waste waste waste; or (2) very good but unsustainably expensive service, they’ve pampered themselves for too long, now those spoiled brats are finally getting their comeuppance and learning that there ain’t no such thing as a free lunch, that’ll show ’em, ha ha.

A couple of weeks ago there was a NPR article on the outsourcing of medical care to India. The care was as good or better. The particular gentlemen they highlighted was from Canada on a waiting list for a knee replacement, and his wait time was lengthy. I cannot remember the exact figures but the price differences of services in India compared to the US was impressive and travel expences were considered.

I’ve always suspected Welch was one of the good guys …

Yeah, praktike, this in particular is brilliant:

Not to be too much of a classist here, but it struck me then that part of the failure to communicate is a logical consequence of the expectation of wealth. Which is to say, of course the health care is better for people of means, so therefore of course it’s better. Expanding beyond health care, this is actually a theme you can see every day, if you look for it — rich or at least well-off people telling the po’ folk how they should behave, and/or how they should interpret the difficult choices they make

though I fear it’ll get him written out of the movement.

Girlfriend’s mom, having avoided doctors and gotten down to an extreme 70 lbs and severe osteoporosis, fell, broke her hip, and had to spend the last 4 years of her life in a hospital with round the clock care. Cost: $50 for the ambulance ride. That’s all.

Her son needed hernia surgery; went to a premier specialist clinic and had it done quite soon. Cost: $0.

“though I fear it’ll get him written out of the movement.”

That sounds Marxist! To the barricades! Anyone with a driver’s license or who has paid taxes in recent years will be shot on sight!

French System
Cost: 9% of GDP
Coverage. EVERYBODY
Rating: #1 in the world by the WHO

U.S. System
Cost: 15% of GDP
Coverage: 43 million people NOT covered
Rating: #37 in the world by the WHO

You’d think that simply enlightened self-interest would be enough. The sad fact is that while we’ve been at loggerheads over “socialized” medicine for 75 years or more, entire generations of other industrialized countries have enjoyed sensible, full-coverage health systems.

However, they are missing out on one thing that our system has in abundance: personal bankruptcies due to medical costs.

Matt redeems himself somewhat in comments by proposing a relatively libertarian solution to health care, but this is still shocking and disappointing. Taking money from the rich to pay for health care for the poor is fundamentally unjust. I don’t care if it works; it’s just wrong.

“French System
Cost: 9% of GDP
Coverage. EVERYBODY
Rating: #1 in the world by the WHO

U.S. System
Cost: 15% of GDP
Coverage: 43 million people NOT covered
Rating: #37 in the world by the WHO”

Could someone please persuade Soros or Gates or some other liberal-ish squillionaire to finance an ad campaign that blankets all media with this stark comparison? The gross ignorance of most Americans about health care in other industrialized countries is what enables the insurance companies to have their mendacious Harry and Louise propaganda taken seriously.

Sorry to comment on a comment (Uncle Kvetch’s). Joel Krugmann just started an NYT series on health care systems, and he does know about France and does not attack the French system.

Jayanne, thanks for pointing this out. I’m going to take a look at Krugmann’s series. If it is, as you say, even-handed, then it marks a real departure from the norm, and a positive one at that.

You’re welcome, Uncle K. I’m going to follow the series and e-mail him (and do a bit of research first!)

Here’s a quote from today’s piece:

>>>
The United States has the most privatized, competitive health system in the advanced world; it also has by far the highest costs, and close to the worst results.
>>>

Link: http://www.nytimes.com/2005/04/11/opinion/11krugman4.html?hp

p.o’neill,

>>>>
Some of the conservative sputtering about French healthcare springs from their assumption that it must be same as Britain, only worse. But that’s wrong. The French system relies much more on private provision and something approaching actual insurance than the British one does.
>>>>

Yes — it’s also 2/3-tiered, i.e., you get more if you pay more, even within the overall system; that would help win over some of your more obdurate opponents of a decent health system… (I do know what they can be like).

But your system is so expensive partly because your doctors are relatively highly paid (we have a similar problem, ours are a lot better paid than doctors in Spain, significantly better than doctors in France) and partly because of your admin. costs. So you need to do more than win non-doctors over…

“Taking money from the rich to pay for health care for the poor is fundamentally unjust.”

Where did I leave my pistols?

Hmm. I should have previewed. I meant that Xavier’s comments are not only morally bankrupt, but stupid, not that the concept of universal health care was wrong or stupid.

Ouch, Jayanne! I have to tell you that I was disappointed when I looked at the Times. You identified the author as “Joel Krugmann,” and I thought this must be the name of a reporter who was doing a series of news items on health care, but it’s actually Paul Krugman, who’s a progressive columnist (and thus is paid to be strongly opinionated). Oh well…it was nice while it lasted. 8^)

My rap on the NYT is that the actual news coverage of this issue (as opposed to the op-ed pages) is consistently, impossibly skewed. It’s not like it’s a frequent topic, but when it comes up, it’s always in service of some master narrative: “It looks tempting until you see how it actually works” or “It worked great for 50 years, but now the wheels are coming off,” or something along those lines.

Without reading through all these entries — too tedious by far — did anyone touch on the 15,000 or so French oldsters who died in last year’s heat wave in part because so many doctors and nurses left Paris in August?

“Does any politician in Canada say “I’m going to bring US style health care north!” ?”

Of course not. The world can get the research benefits of the American system without actually having the US style so long as there is at least one major country to free ride off of. That doesn’t it mean it would be great for medical advancements if the US emulated the other health care systems.

“I don’t know about france… but there are waiting lists in US. I have to wait six months to see my opthamologist”? Where do you live? I can get an appointment with a high level opthamologist despite a complete lack of emergency on one day’s notice. I in fact did so just last week. Is this a particular person you are talking about? Because if so, French-style health care doesn’t give an individual doctor unlimited time.

“U.S. System
Cost: 15% of GDP
Coverage: 43 million people NOT covered
Rating: #37 in the world by the WHO””

I don’t mean to be rude, but formulating it as covered/not covered is an odd way of doing so. People without insurance and without money get treated in the US all the time. It isn’t as if they are just dying like French people in a heat wave. (Yes I’m aware of Chicago. This illustrates the difference between silly rhetoric like ‘uncovered’ and useful discussion).

I don’t have enormous objections to the French system, other than that I worry that the US really can’t emulate it without hurting the world in research–something I’m not at all sure I’m willing to give up. Same problem with defense spending–the world would not be better off with the US emulating European defense spending. This is especially true if it came with a European negotiation ethic. You only have the luxury of waiting as long as Europe wants to in responding to threats if you have someone with huge amounts of military spending to back you up. Its great for Europe, but it is nothing that the US could wisely emulate.

“Does any politician in Canada say “I’m going to bring US style health care north!” ?”

Yes. He’s called Ralph Klein, premier of Alberta. He doesn’t completely call for a US style health care system, but he wants to adopt elements of it. His rhetoric has a following in the country, but hardly a majority.

It always amuses me when people in the US rail against other countries for “freeloading” on American R&D. Excuse me, but other countries fund this process both directly and via the extended patents enjoyed by the pharmaceutical and healthcare industries.

Um, guys, hate to rain on your smug little let’s-bash-the-libertarians party, but there is no sort of libertarian–orthodox, heterodox, radical, moderate, whatever–whose ideology demands a defense of the current US health care system. There are, unfortunately, some libertarians who do engage in such a defense. This is dumb, but says little if anything about the philosophy as a whole.

Also, there is, as Matt W. notes, considerable difference of opinion among libertarians about what to do with health care. But plenty of 100% hard-core libertarians who would *never* accept compromise solutions like Bailey’s still fully acknowledge the immense problems of the current system. We do, of course, tend to differ from most here about the reasons for those problems; most of us think the root cause is not that the system is too private but that it’s not nearly private enough.

>>Taking money from the rich to pay for health care for the poor is fundamentally unjust. I don’t care if it works; it’s just wrong.

>>>>>>>>>
Ouch, Jayanne! I have to tell you that I was disappointed when I looked at the Times. You identified the author as “Joel Krugmann,” and I thought this must be the name of a reporter who was doing a series of news items on health care, but it’s actually Paul Krugman, who’s a progressive columnist (and thus is paid to be strongly opinionated). Oh well…it was nice while it lasted. 8^)
>>>>>

Aaaarrrggghhh I am *so* sorry about that — I thought there was something odd going on, I should have checked. (Yes, I read Paul Krugman regularly.)

I know the series will be an op-ed one still it’s better than nothing.

>>>>
My rap on the NYT is that the actual news coverage of this issue (as opposed to the op-ed pages) is consistently, impossibly skewed.
>>>

I am sorry to hear that, the NYT is usually reasonable — if not particularly progressive by my standards.

>>>>
it’s always in service of some master narrative: “It looks tempting until you see how it actually works” or “It worked great for 50 years, but now the wheels are coming off,” or something along those lines.
>>>>>

points that could well be made of the US health system (if my informants are correct) except, I suppose, that it never worked that well for the uninsured. Not that someone from the UK is best placed to criticise: our system isn’t anywhere near as bad as it’s said to be, but it isn’t as good as the French and German ones, also, Blair’s busily privatising it.

Matt, I had in mind your comment about him “getting written out of the movement” and especially praktike’s response. The idea that most or even many libertarians act like orthodoxy-enforcing Objectivists is silly, and is a convenient way for people to avoid grappling with the real diversity of libertarian ideas and philosophies.

As to the root cause argument: yes, in theory we could improve by adopting a French-style system, though that’s not saying much. The current half-socialist half-corporate massively-regulated hash is probably nearly the worst of all worlds. I think, however, that it could become better still by becoming much more free-market, and I have doubts about the institutional feasibility of implementing a French-style system here (I don’t actually think a Canadian-style system would be better; there are huge differences between the two nearly all of which are to Canada’s disadvantage).

Of course, part of the reason I think the optimum is to go much more free-market is that my definition of “better” is different from yours. In particular, universal coverage is not a goal for me, since I don’t believe in the positive right to rob others under color of law to pay for your sustenance; though I’d not have stated it as categorically and unqualifiedly as xavier, I basically agree with his moral intuition. Just so you know I’m in no danger of losing my Party card. :-)

Sebastian and Bill:

“People without insurance and without money get treated in the US all the time.” “It’s true that people without insurance who arrive ill at an emergency room are cared for…”

It’s worth pointing out that the emergency room is about the most expensive place in the entire health care system to treat someone, and waiting until a condition gets serious enough to warrant an emergency room visit is about the most expensive way you could imagine to deal with it.

Most providers are roughly 50% there to single party payer via their numbers of medicare patients. You don’t hear medicare recipients generally complaining about queuing up or healthcare rationing. The difference between US and elsewhere not discussed on this thread is obesity and income disparity. As recently as the early 1980’s US women over 65 had the longest life expectancies anywhere. The decline subsequently mirrors the take-off in obesity. Let’s see: type 2 diabetes, hyperlipidemia, coronary artery disease, hypertension, stroke, degenerative joint disease, increased rates of colorectal and breast CA, gastroesophageal reflux to name a few results of that upwardly trending phenomenon, and we just so happen to market a few expensive pills for most of these. Single payer can provide relief for the income disparity portion of the problem, but as far as the major trend-setter in this country’s health decline is concerned, it’s probably time to ration the Ben & Jerry’s.

[i]Yes. He’s called Ralph Klein, premier of Alberta. He doesn’t completely call for a US style health care system, but he wants to adopt elements of it. His rhetoric has a following in the country, but hardly a majority.[/i]

Technically adopting elements of the US health care system would make Canada more European than American — most European countries have more room for private health care than Canada’s system (where, unlike in France, the waiting lists and inefficiency are real enough problems).

Matt, I had in mind your comment about him “getting written out of the movement” and especially praktike’s response.
——-
You protested, and then proceeded to go off into a rather Objectivist moral stance against the very idea of progressive taxation. Odd.

Well, Praktike, Nicholas’s moral pronouncements aren’t necessarily Objectivist. Robert Nozick would’ve agreed with those pronouncments, and he was no Objectivist, nor (I’m pretty sure) an orthodoxy-enforcer.

But my point wasn’t about orthodoxy-enforcing–it was that Matt Welch’s comments seemed to strike at the very heart of libertarianism. I guess they’re not strictly incompatible with the tenets of libertarianism–you can think that all taxation is morally wrong (except as required to support the minimal state) and also think that the rich ought to better understand the choices the poor have to make, I guess–but they’re in pretty serious tension. Matt Welch seems to be saying that social systems should be judged by how well they do by the poor, whereas libertarianism of most any stripe seems to be committed the idea that social systems should be judged by how much freedom they give to people’s purchasing power.

So I don’t think it would be rigidly orthodoxy-enforcing to say that Matt Welch’s comments–the parts that don’t have to do with health care–aren’t something that a real libertarian would say. If some liberal said to me, “You know, taxes are in themselves a very great evil,” I’d say, “You sound like you’re more of a libertarian in disguise.” If some libertarian were to say to Matt Welch, “You sound like a liberal in disguise,” I don’t think that’d be unreasonable or rigid. I say that to him.

(But–Brewers to win the NL Central? One of us is going to be looking silly in October.)

Hi Jonathan,
Your point about the cost of ER care is well-taken. Careful, though. I have seen some hospital accounting from the inside & what is charged in ERs isn’t necessarily well-correlated with what it costs. What is even more troubling is that when you get your care through the ER, you have no ongoing relationship with a physician. Continuity of care matters.

It is also important to note that although you can get treated without insurance at an ER, it won’t be free to you unless you are truly indigent.

“Brewers to win the NL Central?”

Troubling indeed.

I have to second the claim that much of the libertarian bashing that is going on here overlooks the diversity of opinion among libertarians with regards to health care. Here’s one good article by Ronald Bailey that I suggest people read:

http://www.reason.com/0411/fe.rb.mandatory.shtml

I don’t agree with all of Bailey’s arguments, but I think the overall thrust of the article is correct.

Thanks for the links, javier.

I’d also recommend, though it’s a bit dated, Richard Epstein’s book Mortal Peril. Any definition of libertarianism that would read out Epstein is very narrow indeed.

it was that Matt Welch’s comments seemed to strike at the very heart of libertarianism.

You can regard two policies as undesirable but still regard one as more desirable than the other. Certainly most libertarians would say that a true free market in healthcare would be ideal. But given the choice between the un-libertarian system in the US and the un-libertarian system in France, the ideology doesn’t pick a clear winner.

Childbirth should never be insurable in a society with birth control and legal abortion because it’s not a risk. If you require it to be insured you’re simply transferring wealth from those who don’t want kids to those who do. If that’s what you want to do, mandatory health insurance for hospital costs incidental to childbirth is a pretty inefficient way to do it.

There’d be just as much basic research (and shouldn’t a real libertarian oppose that, by the way, since it’s almost all government funded?) There’d certainly be a lot fewer me-too drugs developed and marketed at great expense to no public health benefit. Whether there would really be a deficit in genuinely useful new drugs (which, to big pharma’s chagrin, actually don’t come along all that often) is at best unproven. I note that it’s almost always economists- who generally understand very little about science- who make these alarmist claims.

There’d be just as much basic research (and shouldn’t a real libertarian oppose that, by the way, since it’s almost all government funded?) There’d certainly be a lot fewer me-too drugs developed and marketed at great expense to no public health benefit.

Steve, do you have any evidence for this claim? I’m not trying to pin you down, I’m just genuinely curious about this topic. Do European countries with nationalized health care produce as much basic research as the United States?

And what some examples of some “me-too drugs”? Some potential examples are antidepressants, cholesterol drugs, diabetes treatments, and anti-psychotics. These have mostly been privately produced and marketed, and have generated massive profits. But anecdotally at least, I’ve observed first hand that these drugs have greatly improved the quality of some people’s lives, including the lives of several family members and friends. Wouldn’t shrinking the market in pharmaceuticals reduce the kind of innovation that produced these drugs?

P.S. Most of the profits of the pharma industry come from rent seeking in the form of government patents- another thing that’s hard to square with libertarian ideology, n’est-ce pas? So we have a situation where almost all the intellectual basis for new drugs comes from reasearch funded by tax dollars, and almost all the big profits the pharma companies allegedly need to finance the final steps of drug development come from exploiting the patent laws. Do you see why I’m having trouble understanding how libertarians, of all people, supposedly know how to maintain the flow of medical innovations?

Steve, you’re certainly right that before WWII we had a much more capitalist health care system; indeed we had a much more capitalist system before 1965.

And that goes right along with my point that the medical advances we now enjoy- I’ll specify, if our like, those since 1965- came out of a system that at at no stage and in no respect had much resemblance to a free market. The vast majority of the actual science underlying new drugs comes from research directly funded by the taxpayers. Until you and Javier deal with these facts, your arguments appear faith-based rather than empirical.

Of course you can have a bad, inefficient government-based system- that is indeed what we’ve had since around 1965. You’re arguing against a straw man- nobody is claiming that government intervention always and necessarily produces good results. On the other hand, there are in observable fact a number of single-payer systems that produce markedly better results for markedly less expenditure. (Where are the pure free-market systems, or anything even close, so that we can judge their actual performance? More faith-based argument.) If your biggest worry about these is loss of future medical progress, you’ll have to expand your argument quite a lot before I start to share that worry.

“The world can get the research benefits of the American system without actually having the US style so long as there is at least one major country to free ride off of.”

For such a long-lived and frequently conservative talking point, there’s little actual evidence to support this. Where’s the regressions, Sebastian?

jayanne (comment 8): As far as I know, having (and paying for) “public” health insurance is only mandated for members of the “worker’s club” in Germany, i.e. employees. And then only with incomes above a minimum and below a cap. Others are free to choose between the public system or private insurers, or go without. (Civil “servants” kind of have their own system.)

Not quite sure what others could have mandatory insurance. I think it’s only workers of various descriptions.

Insurance premiums are around a nominal 14% of gross income. For employees, the employer has to pay 50% as a “hidden” wage component.

Healthcare is provided to unemployment and welfare recipients through one insurer (AOK) to which the others have to make transfer payments.

Nicholas, that’s the standard drug-company propaganda line, and it’s partially true but misleading. (Especially since an honest accounting, which we’re unlikely ever to see, would probably show that their real R & D expenditures are embarassingly modest when compared to their marketing expenditures.) Other arrangements most certainly could be made to do the parts of the process they do. The most useful drug of all time, penicillin, was brought to market, after a long delay, through the action of the US government which wanted it availalbe for servicemen after we entered WWII- not by any initiative from the pharma industry.