No. 2 in an occasional series: Alex Tabarrok on France-US comparisons (with minor editorial changes)

The campus cafeterias close after lunch.

Duh. I dare you to find one restaurant anywhere in France with kitchen open between 2 and 7pm.

Although it hasn’t digitized medical records yet, Medicare works nearly as well as the VA system.

A few months ago, I interviewed Dr. Quentin Young about universal healthcare. Dr. Young was chairman of the Department of Internal Medicine at Cook County Hospital, and is now Clinical Professor of Preventive Medicine and Community Health at the University of Illinois Medical Center and Senior Attending Physician at Michael Reese Hospital.

Here’s an excerpt:
What’s the most common misconception about universal, single-payer?
“It’s ironic that people think you lose choice in a single-payer system. That might be true in a socialized system, like Cuba’s, but that’s not what we’re proposing. We advocate that the government be the insurer, and we already have such a single payer system in place for people over 65. It’s called Medicare.”

The obstacle to be overcome is the deep-pocketed and well-organized insurance companies, who have managed to enlist a large number of physicians as allies.

It’s difficult to imagine an efficient universal program in which insurance companies play a role, but they will not go away gently.

Nothing will happen until there’s a Democratic landslide of 1964 proportions.

This one’s easy. The key word in ‘health insurance system’ is ‘insurance’. Insurance markets are generally prone to market failure (not that government attempts to fix this cannot be a greater failure) so it makes sense that government intervention could make it work better.

On the other hand university education should work better in a competitive system than when ran by a micromanaging government. While it generates research externalities and the like this is essentially an argument for some subsidies not outright control and regulation.

So US should have France’s health care system (if it could be transplanted) but France should have US’s university system.
No puzzle here.

is it possible that Americans as a whole lack the knack for socialism in any small or large sense of it? European countries seem to have a fair grasp of its idea and how to implement it in some circumstances, not to say that it doesnt fail at some points. America just seems to be caught in this Cold War vacuum, where 20 years later any sort of government control or implementation of social programs sets the conservatives off on a rampage.

Methinks Tabarrok confuses the cream of the crop of American universities with the domestic postsecondary education overall. There is a tendency (including from European PoV’s) to look at Princeton and point out how overabundant resources are at American universities. Sadly, for the vast majority of students in the U.S. the reality of campus life is much closer to Paris XII than Princeton, at a significantly higher cost. If you want to compare the US system at its peak with the French system, you better looks at the grandes écoles.

I went to UC Berkeley, and it’s a lovely place, even though it sucks off the teat of the state.

And of course, private US research universities get piles of government grant money, so it’s hard to argue that they’re purely a capitalist enterprise. They somehow get away with charging higher grant overhead % than public universities, or at least they did when I worked on NCI-funded projects back in the day. You’re going to have a hard time arguing that Princeton is more “efficient” than UC Berkeley just because it’s private.

If you want to look at purely capitalist universities, you have to look at the for-profit sector (i.e. DeVry, Heald, U of Phoenix, etc.) Frankly I don’t think the people going to the grands écoles are too envious of those…

If you want to look at purely capitalist universities, you have to look at the for-profit sector (i.e. DeVry, Heald, U of Phoenix, etc.) Frankly I don’t think the people going to the grands écoles are too envious of those…

Or the for-profit-and-Jebus sector (i.e. Fallwell’s Liberty University), which is a ‘pure product of America’ in the William Carlos Williams sense.

Anyway, Tabarrok’s ‘most admired… in the world’ line is more than somewhat vague in meaning. Most admired around the world, in the sense that US universities attract foreign students? Well, those foreign students getting visas aren’t going to community college. Nor are they enrolling for an undergraduate degree, for the most part: take Alex Tabarrok, for instance, who arrived at George Mason with a B.A. from Canada.

‘Most admired’ in terms of global criteria for enrollment and graduation? Well, again, we’re talking about American undergraduate degrees here. Define your terms, mate.

Of course Europe has a problem with elite education because of the egalitarian system.

Bwahahahahahahahahaha. If there’s a problem, it’s with the idea that an ‘elite education’ should come with an elite price-tag.

Sigh.

Sorry to be heretical here, but the European systems of universal health care insurance leave a lot to be desired.

Has everything to do with demographics and the declining number of people who can actually fund the system.

I live in Germany and have been in the system here for 20 of the last 24 years.

None, and I repeat none, of the European health care insurance systems are fundamentally fiscally sound. The basic problem is demographics and the fact that an increasingly older population is driving costs in such a way that only government limits on how much workers can be dunned prevents them from raising rates to where they need to be.

I’m a voluntary member of the state insurance system here, voluntary because I earn well above the maximum where I can opt out of the system and choose private insurance. I pay 528€/month, which my employer matches for a total insurance load of €1056/month. I am one of the people helping to finance the system here: I would have better coverage in the private sector, but I simply refuse to enter the private sector as a matter of principle, since I have good friends who work in the public sector and it is, fundamentally, a good idea that is slowly being destroyed by demographics.

For that €1056/month I get extremely basic coverage which does NOT include things like eye care or dentists. It once did (15 years ago), but now that’s been dropped. What I do is pay for people like my mother-in-law, who is paying virtually nothing for the same coverage I get.

The problem, to reiterate, is demographics. Whilst young folks generally get the care they need without much delay (including some elective surgeries), the health care for the elderly is severely rationed. Not that someone with a broken hip in their 80s doesn’t get helped: but the hip won’t be replaced, but rather pinned together and the patient put on a permanent regime of pain killers, because it’s simply not cost effective to give them a new hip.

I discussed two concrete cases with my doctor, a GP within the public sector, to see what he would be allowed to do under the circumstances. One is an 84 year old male who had a stroke, fell and broke a hip and three ribs. Under the German system, he would have ended up in a wheel chair, since the hip replacement is contraindicated beyond the age of 80. The other is a 70 year old male who has an increasing problem with scoliosis of the back and degneration problems with his backbone. He would have also ended up in a wheel chair, since the necessary operation(s) were contraindicated beyond the age of 65 (multiple rods in the back to correct the backbone problems).

Which would have meant that both my grandfather and father would’ve been in wheelchairs for the rest of their lives, instead of leading active and productive lives for another 10 years in the case of my grandfather (2 hip replacments) and continuing activity with my father.

Of course, these operations cost a sh*tload of money. My grandfather was insured by his previous employer and Medicare; my father as well.

To reiterate, under the German system they would’ve had this care rationed. That is, in reality, how the Germans are taking care of their increasingly elderly population, by rationing the health care in order to not bankrupt the system.

And interesting that no one here mentioned the 15000 deaths in France of their elderly there last summer when everyone in the country was on vacation.

So transplanting any sort of European health care insurance system means that you will need to talk about rationing health care to those who cause the greatest costs, the elderly. If you’re comfortable with that, go ahead, but explain to everyone in advance that it may well mean that grandma and grandpa won’t be getting some of the care they need because no one can afford to pay for it.

Just look at all the problems of the British system to see what at least could happen. On paper it looks great, in reality? Get real. There are real reasons why the NH is vilified in the UK. Having a heart attack? Get in line.

Check reality before making recomendations: while there are many who either chose not to have health insurance or who cannot afford it, the quality of care in the US is superior to that of Europe as a whole. Hospitals carry the cost of providing that and pass it on to the insured in the form of high costs for those who can afford it. But it’s a system that ensures that explicit rationing is NOT in place, which it is in Germany.

Tim, for some people, it’s all the same – Evul Soshulizm.

dd – “Don’t all of the countries that beat the U.S. have k-12 systems dominated by monopolistic, government provided schools?”

Not only that, but how many of the countries which beat us have as large a proportion of private schools as the US does? I’d wager that at least some of the US-beaters are doing it with almost pure gov’t schools.

Barry, take the private schools out of the US system and not much would change; elite k-12 schooling in the US is mainly provided through government-run schools (in very welathy suburbs); the private school system deals with religious kids, at-risk middle class kids, and others; the “elite” is a tiny percentage of the private system. France relies heavily on private (but government funded schools); Canada has a very complex system of choice which is in effect heavily privatised (but again, government funded). The general points here all stand though; it is the research and graduate element of US universities that is widely admired, not undergrad education, and anyway its mostly heavily funded and regulated by the Feds and/or the States.

I have a real problem with these kinds of debates, as different things are being compared. To give a few examples. Yes there are real problems with the NHS, but then it is a healthcare system done on the cheap (both the US and Europe spend significantly more on their systems), where doctors effectively operate a cartel on how many new doctors can be trained (whereas France and Germany have a surplus of doctors), one reason for the waiting lists and higher salaries. Simplistic arguments about private vs public are meaningless in this context. Many of these arguments tend to come down to complaints about inefficient bureacracy – but that can be as bad in private sectors (such as the insurance claim system in the US).

John F. Opie argues that the German system has a problem with demographics – there are not enough young people to pay for the system. Quite possibly, but that’s not going to change by privatising it, so I’m not quite sure what his argument is supposed to be there. Yes, the US system is wonderful if you have good insurance – most people don’t. Health care in Germany might be rationed, but then it is in the US based on ability to pay. There are plenty of old people in the US who won’t get hip replacements either, and probably can’t afford the painkillers either.

Similarly comparing US and European universities is similarly simplistic. It depends upon what purpose is required from the university system. Is it for research, or teaching? Should it being teaching an elite very well at the expense of the rest, or should the money be distributed more equitably? And anyway, is this particularly relevant given the inadequacies of the tertiary schooling system in the US?

“The US has one of the most deplored health insurance systems in the world and one of the most admired veterans’ health care systems.”

Incredible.

The VHA has made a tremendous turnaround from it’s low point in the early 90’s. I did some research at the VA in LA and clearly remember the rows of nodding old men lined up in the hallways in wheelchairs, jacked up on demerol, and … smoking. The changes were forced by the possibility of being doomed to obsolescence. The changes can’t be causally attributed to the method of payment administration. The government was the single payer when these VA hospitals were at their worst and now, at their best. Nevertheless, the naysayers who claim that comprehensive health systems can not be run well under a government single payer system are wrong.

There are other, premier medical centers that run equally well or better than VA medical centers. They are non-commercial institutions (like Mayo) that use a mixture of payers from private insurance to Medicare. Obviously, private systems can and do work. They end up costing more in the long run. And that’s reason enough to change to a government-run single payer system.

In the final analysis, the medical model is what ensures quality of care. The VHA adopted a value driven, patient centered medical model much like that of the Mayo Clinic. And it worked.

The VHA may have made a tremendous turnaround from the early 90’s, but it is still below par. The VHA relies heavily upon non-VA hospitals and then pays VA rates for the service. This can take months to schedule and then years to negotiate the final price, and which the patient will carry the debt until the VA pays.

From the veterans I know (yeah yeah yeah, antedote doesn’t make date), I’d be extremely skeptical of any study claiming the VHA was doing a better than the over all system. Probably rigged anyway, with the VHA being compared to an elite (expensive) set of hospitals catering to old rich people.

Comment #4 is key; doctors in the US make a LOT more than doctors in other countries (IIRC, average income for a Primary Care Provider in the US is 2.5x that of a PCP in France, and the disconnect is even greater for specialists.)

Because the US does not have a single universal health care system, it is ludicrous to compare the aggregate of US health systems to individual health care systems in Europe. Single models in the US should be compared to single models in Europe. Just the first sentence in Henry’s post highlights the strange comparisons so common in these discussions. First, comparing insurance systems to health care systems, and, second, comparing the whole “most deplored health insurance systems in the world” to the VHA which happens to be part of that whole.

Jet, comparison studies in quality of care have been done between the VHA and commercial managed care systems. That’s a far cry from comparing the VHA to premier US medical centers. Hospital ratings that include all hospitals don’t have VA hospitals high on the list.

The patient satisfaction surveys are not rigged; they are just not properly controlled. Crudely put, VA patients are a different population from the general population. Still, the VHA has improved dramatically compared to 15 years ago. Canada, for instance, looks to the VHA to see how they can improve their health care system.

I can think of a relatively easy way to measure patient satisfaction with the VA. The VA provides care to veterans and their dependents. For people who can choose between the VA and other health care plans (which is to say most veterans with full time jobs), find out if they use the VA (which they have largely already paid for by military service) or if they use their job’s health care (which if they have dependents they have to pay much more for). Anecdote not data of course, but in San Diego (with a good VA hospital closely affiliated with the well respected UCSD Medical School) with veterans whose medical choices I have some idea about (four) all prefer to use the insurance provided by their companies instead. Two have Scripps which makes it understandable, but two have Kaiser which despite their rather slick marketing campaign, at least in San Diego (local health insurance markets may vary so I figure I will give as much information as possible), has a not-so-thrilling reputation for being stingy and otherwise annoying. It seems to me that if people who have a choice and have experienced both choices consistently choose the non-VA option, that should be a good hint that the VA isn’t so wonderful. Is there somewhere we can get such statistics on a large scale? If not, maybe one of our academic friends could get a grant. :)

“In effect, cost containment and quality at the VA is sustained with subsidy from other health care providers.”

I would be completely unshocked to find that is true. But my point in mentioning UCSD was that the VA here should not be thought of as some out-of-the-way awful old institution. It is modern, has access to excellent doctors and nevertheless appears not to be preferred.

This is a pretty absurd debate. I’ve lived in the US and I now live in Italy. I’ve been to hospitals in both, but if I were sick, I’d much prefer to get treatment in the US (in fact, just the threat of having to go to an Italian hospital has made me live more healthily. But I will say that the main failings are with the infrastructure; the doctors here seem excellent).

That being said, there are pros and cons to each system. There is no ‘one best’ system; there are just different failings in each.

While being far from an expert, I’ve been spendng an inordinate amout of time thinking about healthcare systems and increasingly I’m of the mind that the healthcare system is inconsistent with capitalism. That is not to say, though, that all aspect of healthcare should under control of the government, and it’s not even the same as saying the government could do the best job.

Which country has THE BEST healthcare system in the world? Let’s start with that, and then improve upon it…

Let’s think of a metric for the overall effect of the education system.

My guess would be productivity/hour.