Frankly I'm stunned to see either you or Drum accepting the vile right-wing label "gold-plated" for what we now consider barely acceptable health insurance. It's a phrase invented by people who insist that "we have the best health care in the world" to describe barely adequate care for people who don't have as much money as them.

In right-wing land, "gold-plated" health care means they won't revoke your policy once they discover you have cancer. And of course it should only be available to the wealthy. The rest of us should consider the moral uplift of battling our own illnesses with our bare hands.

"translated into kanji"

Uhmm, you don't "translate" anything into Kanji. You may translate something into Japanese (a language), or you may transliterate something into Kanji (one of several scripts used to write Japanese). When you translate into Japanese, the resulting words may be written using Kanji, but they may just as well be written using Hiragana, Katakana or a mixture of those.

Dude, unless you were planning to tattoo that across your tight, hard abs, it's just sad. :)

But yes, this is what I too have believed all along.

Although my tattoo reads "I am so freaking hott - I got what the beaches want". In Arabic. :)

The problem is that Ezra's and Kevin's logic can end up forcing the poor and middle class into crappy care. When we say that health care is a right, we shouldn't mean that you have a right to be forced to purchase insurance by government mandate from a crappy HMO that will use coverage boards and bureaucracy to deny you coverage and kill you when you need a medical procedure.

Like Kevin, I have no problem with the rich purchasing care over the minimum guaranteed by the government. What is non-negotiable is that the government guarantee the health care-- not force individuals to purchase it; and it be good health care-- not crappy care.

A minor quibble: There's at least some evidence that statins--at least at the levels prescribed--really aren't very cost effective or useful for millions of people. See Maggie Mahar here, for example:
http://www.healthbeatblog.org/2008/02/the-cholesterol.html#comments

Otherwise, yeah--all very true. Being cost-effective and reducing costs, while closely related, are distinct.

Ezra, you don't really have tattoos, do you? A nice Jewish boy?

When you mentioned Kanji, I had a flash back to flipping Kanji cards in a vain attempt to memorize 50 a week back in undergrad. Thanks for bringing back the bad memories!

...but that's a pretty perfect description of how I understand the role of the progressive health reformer. It's also why I joke at panels that my plan for health reform is invading France and taking their system.

Ezra,

The devil is in the details here. Specifically, what is considered "gold-plated" versus "decent care." Under any reasonable analysis, what you and Drum are supporting is providing all Americans with something less than the benefits of Medicare, and very likely less than the Federal Employees Health Benefits Program.

On a similar note, as I've asked before, I'd be interested in a detailed assessment of the supplementary role of markets in the French system. Based on my cursory examination of what's covered in "basic" versus the supplemental plans, there is little practical difference between "single-payer" and the French system. Meaning, the basic plans cover most everything that people care about, and the supplementals involve further shielding from co-pays (horrible idea), plastic surgery, dental care and a few other items. This needs further exploration-- there's too much acceptance of "France is a hybrid" when reality may be that its more of a minor deviation from single-payer.

brad beat me to it. Maggie Mahar is my favorite.

I heard it said recently that the trade-off for universal coverage is mediocre care. Taking that at face value, let's look at it from the other side: the USA has licked the problem of mediocre care by having the very best care available to a relative few.

Some are satisfied with that as an end solution. Others see it as yet another problem to be solved.

Grumpy:

The trade-off for universal coverage is not mediocre care. If the government provides or pays for health insurance or medical care for every American, we can make the care as good as we want, constrained only by the amount we wish to spend.

The trade-off for an individual mandate, on the other hand, is mediocre care. And the combination of forcing people to buy insurance they can't afford and forcing them into terrible insurance policies that will kill them when they need care is not any better than the current system. It is worse.

Ezra needs to get over his love affair with the French health care system. It has very, very serious problems, most importantly the fact that it is chronically underfunded. They can't go on the way they have been for the past two decades. The French are facing massive cuts in services, or massive increases in taxes and fees, or both.

Wisewon:

Here is a link to an excellent discussion of what goes on in the French health care insurance system – warts and all. It was written in 2003 but the structural situation in France – from where I am writing – is still basically the same.

And your insight that the French system is more a "minor deviation from single-payer" than a so-called hybrid system is on the money. Yes, there are de facto multiple payers in the French system. But the key thing is that the government is the "big dog" who sets the rates – at least for basic coverage. As I have argued elsewhere: "[T]o say that the French system is not monopsonistic, especially at the level of basic coverage, is arguably a distinction without much of a difference."

Jason:

No doubt there are cost pressures in the French healthcare system, as there are in any healthcare system. But I wonder if you might post links which would provide reasonable justification for your suggestion that:

"The French are facing massive cuts in services, or massive increases in taxes and fees, or both."

Try to be explicit on the definition of "massive" in both cases, and the time frames for when these Armageddons are expected to hit.

Hint: please provide links which don't come from just the right leaning politicians and analysts in France – or elsewhere. After all, we know that we can get even a Democratic candidate for president in the U.S. to repeat mindless right wing talking points about Social Security being "in crisis," something anyone who has the good sense to read this blog knows is laughably false.

From the The European Observatory on Health Systems and Policies, which is a partnership between the WHO and a number of European governments:

In addition to compulsory health insurance
covering all legal residents, the market
for private voluntary health insurance
(VHI) is well developed in France. VHI
mainly covers user charges that are not
eligible for reimbursement by the public
health insurance system: co-payments for
ambulatory doctor visits, a per diem
charge for accommodation in hospital
and extra billing authorized for a small
number of ambulatory doctors. It also
covers the difference between actual
prices charged and official reimbursement
tariffs, which are particularly high
for dental prostheses and spectacles, and
may reimburse medical goods and
ervices that are not on the public health
insurance funds’ positive reimbursement
lists. Finally, it covers the cost of facilities
such as a single room in hospital.

Was curious if my recollection was correct. It appears that it is. This level of detail on the French system isn't my area of expertise, but I read a few things over the years consistent with the above description. This isn't, in my view, a "hybrid system" or one that will "provide decent care to everyone, with the market free to operate on top of that." Its still essentially a single-payer system, with a supplmental market that allows people to shield themselves from the cost-sharing designed to help control utilization.

Source:

http://www.euro.who.int/document/Obs/EuroObserver6_1.pdf

Try this:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2043071

Quotes:

"The French national insurance system has been running constant deficits since 1985; the deficit now tops $14.77 billion. Public spending on doctors' consultations and treatments this year alone was $2.76 billion over budget, by early summer. The government had hoped to hold health care deficits for all of 2007 to $1.52 billion."

"It will be the generation now entering the workforce who will pay for the years of deficit spending through some mix of higher taxes and reduced access. All of this is made worse by a looming demographic crunch. With the number of French aged 65 and older expected to grow from about 16% of the population (according to Council of Europe projections in 2003) to an estimated 24% by 2030, the pool of workers contributing to the social security system will be greatly outnumbered by those needing increasing care and medical services."

The piece concludes:

"Yet, the modesty of Sarkozy's user fees reveals that it would be political suicide for any French government to radically limit health care access to a populace who have grown used to Michael Moore's ideal of access to free health care as a fundamental human right. And it may be economic suicide not to."

Also, see this:
http://www.guardian.co.uk/world/2004/jan/24/france.jonhenley

The title of the piece, "French health service on verge of collapse, says commission" sums up the dire state of the French health care system.

Ah, Jason has those five links to support his ideology -- three for France, two for the UK -- and he's going to use them, year upon year upon year.

In pseudo's world, of course, evidence is irrelevant, and wishful thinking is all that matters.

Jason,

What you lack is perspective. Let's look at the numbers more closely. A $14.77B deficit in France, divided by 64M citizens, is $231 per capita. Taxes would have to be raised by that much annually to cover the cost.

The French expenditure on health care wouldn't change if they raised these taxes. It would still be about 54% of the US expenditure per capita (using 2003 data).

The United States, by the way, is engaged in massive deficit spending in order to cover the cost of the Iraq war, and so programs such as Medicaid, TRICARE or even FEHBP which draw from general Federal funds also "contribute" to the deficit to the tune of many billions of dollars.

So remind me, who has the crisis in funding their health care system?

Ezra,

There is an important distinction commonly missed about the benefits of preventive care. It's true that it may not reduce total costs because as people live longer, particularly into old age, they have a longer time with which to deal with chronic illnesses and the various infirmities of age. And in any case, on average roughly half of health care expenses occur in the last few years of life, regardless of whether one dies at 45 or 85. Sooner or later something will get you, and it's generally something we spend a lot of money trying to stave off.

However, that does not mean that preventive care is neutral with respect to making health care more affordable. If people are living longer productive lives, they are growing the economy to a greater extent and they are contributing for a longer period into the financing of the health care system.

Take someone who is healthy until 65, then retires because they only expect to live to 75 and by 70 starts adding on chronic illnesses until they die at 75. Compare that to someone who is taking better care of themselves due to various public health and personal preventive measures, who (reasonably) expects to live to 85. That person may continue working to 70, contributing for an additional 5 years into the national economy and into financing the health care system much more than the person who retired at 65. This will lower the national expenditure on health care as a fraction of GDP, even though it doesn't lower the total cost of health care, assuming a similar pattern of health until the last 5 years of life.

Of course, there is a lot more complexity affecting the net impact. For example, the share of GDP for healthcare would be further reduced by a reduction in disability payments for working age adults, and by an increase in those who work to retirement age as opposed to dying young and losing out on their full productive years. On the other hand, as retirements stretch on in length, this would be a factor increasing the share of GDP devoted to health care.

I don't know if anyone has run these projections, but I think that for a while at least, the net gain from preventive care in terms of productivity would more than compensate for the net drag in terms of people living longer in retirement and drawing from the system.

wisewon,

You write that the use of supplemental insurance in France to shield citizens from copays is a "horrible idea." What is the evidence for that?

There is evidence that eliminating at least some copays for preventive care and maintenance drugs has a net positive effect on health care expenditures.

But more importantly, in looking at France, is there any evidence that removing copays is causing a problem with national health care expenditures? After all, most people in France have supplemental insurance, and their expenditures are still a fraction of expenditures in the US per capita. It seems their lower "skin in the game" hasn't been a problem for them, or any other national health care system. At least, not a problem compared to the ones we've created for ourselves here despite the greater skin in the game had by Americans.

We need to reduce administrative bloat.
We need to reduce rates of payment (to get physician and hospital revenues closer to peer nation averages).
We need to reduce incentives to providers to focus on volume of care rather than quality of care. (Nice article on that in the NYTimes here.)

If we are able to do those things through a coordinated national system (like every other peer nation does), then having less skin in the game in terms of copays or coinsurance will not make much difference at all as a matter of national expenditures.

jd has a good point but THE point you and other folks like you miss is this:

Health care cannot be a for profit activity without costs spiraling out of control.

How can that be you wonder? Well, there are a lot of reasons some technical some human. I put it to you that rather than obsess over the 'French' system or whatever you should simply look at the number. EU nations, in the aggregate pay less per capita, less as a per cent of GDP, their citizens live longer healthier lives and their kids are healthier.

Get over the Libetarian bs and check out Angry Bear's series on health care America vs. EU and let's get with the program.

Free, not-for-profit healthcare for every American.

Start here:

http://angrybear.blogspot.com/2005/04/real-crisis.html

He's got eight posts with all the numbers. It's no longer a subject for debate unless you are a McSame supporter.

Are you?
.

jd,

Let's look at the numbers more closely. A $14.77B deficit in France, divided by 64M citizens, is $231 per capita. Taxes would have to be raised by that much annually to cover the cost.

The $14 billion figure is for 2004. By now, it is even higher. The French government's own commission projected the deficit to be 29 billion euros by 2010. That's about $45 billion. Which is about $750 per person. Which is $3,000 for a family of four. I think you're the one who lacks perspective.

The French expenditure on health care wouldn't change if they raised these taxes. It would still be about 54% of the US expenditure per capita (using 2003 data).

The ratio of French spending to U.S. spending is not the issue. We pay a lot more for health care because we consume a lot more health care resources, and for other reasons, such as our higher labor costs. The point is that the French health care system is unsustainable. They cannot cannot fund their consumption through public insurance. They've been spending money on health care they don't have for 22 years. The system is going bankrupt. That's why the French government commission said the system will "collapse" within 15 years without "fundamental" reform.

The United States, by the way, is engaged in massive deficit spending in order to cover the cost of the Iraq war, and so programs such as Medicaid, TRICARE or even FEHBP which draw from general Federal funds also "contribute" to the deficit to the tune of many billions of dollars.

Medicare, like the French health care system, is also going bankrupt. We're not funding even our present public health care programs. It's a fiscal train wreck in progress. Fix Medicare, THEN you might be in a position to demand more money from taxpayers.

Jason,

I was using the number you quoted, but if you want to pull the ball as I kick it, fine. It doesn't change the overall conclusions. Your essential claim is that we should not emulate the French system, and we should not do so because it is not "sustainable," and this somehow results from the fact that it is mostly government-supported.

You cannot seriously mean to say that the French system is unsustainable but the US system is sustainable. Or do you mean that the commercial part of the US system is sustainable, even though the medical cost trend there is actually higher than in the government-sponsored programs?

Or do you mean that the French system and US system are both unsustainable, but the French system more so? But then, how could a sector that takes around 10% of national GDP be less sustainable than one that takes 16% of GDP? Please explain how that makes any sense.

One way to answer the question of sustainability is to point to the share of national GDP and the rate of growth in the sector compared to growth in GDP. We know the relative shares of GDP (10% and 16%). Last I looked at the 30 year trend, France was in better shape on the rate of growth issue than the US as well.

Finally, all this talk of deficit spending gets easily overblown. We need to ask: what is the deficit as a share of national GDP? To talk of Medicare going "bankrupt" is idiotic, and I don't use the word loosely. Medicare will not go bankrupt until the United States government goes "bankrupt," by which I mean that it finds itself unable to pay off its obligations. And since it can always print money, it will never need to go bankrupt (and in any case, technically it cannot do so, since there are no laws establishing a state of bankruptcy for the national government...it's not like it can file for chapter 11). So for both technical and non-technical reasons, the US will not go bankrupt.

What can happen, of course, is hyperinflation if the national debt gets too large. That is a real risk some time out in the future, but Medicare would be only one part of a giant mess, of which debts from the Iraq war are likely to loom larger for at least the next 15 years.

This is why you are absolutely wrong, by the way, that the ratio of French spending to US spending is not an issue (I grant it is not the only issue). The more it costs as a share of GDP, the harder it is to finance. In a world where politicians are weak and introduce programs without also the funding mechanism, that adds big deficits....bigger as the total cost of care goes up.

jd,

You fell into a common problem with these discussions-- a criticism of part of the system, is not a criticism of the system as a whole. Clearly, the French system is in better shape than ours overall. So the bottom 80% of your post wasn't necessary.

You write that the use of supplemental insurance in France to shield citizens from copays is a "horrible idea." What is the evidence for that?

This was a minor side point, you completely ignored the primary point which is the one that merits further discussion. But anyways...

Three points, jd. 1. RAND studies demonstrate effects of cost share on utilization. (I'm aware of the controversy. Its common sense.) 2. The French system demontrates this. In 2000, they further reformed their system to give free VHI (supplemental) to low-income residents because they had a lower access to care since they couldn't afford VHI and the cost-sharing limited their utilization disproportionately. 3. France, and most other Western nations, still have significant issues with rising costs. Better than ours, for sure, but they need further cost control. Look at the numbers, read the country-specific policy papers. Increased cost-sharing is commonly cited as a solution. Not sure where the controversy is here.

There is evidence that eliminating at least some copays for preventive care and maintenance drugs has a net positive effect on health care expenditures.

Of course, jd. I didn't say all cost-sharing is good. Sheesh. I think your multiple posts to Jason got you on a roll in a bad way. You want preventative medicine? Ignore him. He's bad for your health.

But please let's not lose sight of the primary point I was trying to make. France is known as a "hybrid" giving the private market a role in providing people more than a "one size fits all approach." The details suggest otherwise. The benefits are pretty much the same for everyone, the supplementals provide further financial protection. That's a very different picture. That's still pretty much single-payer.

This is more for Ezra, but the point is that I think few really understand how supplemental insurance works in France. It doesn't work the way many commonly perceive, as Ezra wrote in his Health of Nations piece below:

Yet France's system is hard to beat. Where Canada's system has a high floor and a low ceiling, France's has a high floor and no ceiling. The government provides basic insurance for all citizens, albeit with relatively robust co-pays, and then encourages the population to also purchase supplementary insurance -- which 86 percent do, most of them through employers, with the poor being subsidized by the state. This allows for as high a level of care as an individual is willing to pay for, and may help explain why waiting lines are nearly unknown in France.

This isn't correct. There is, practically speaking, a ceiling. Its the benefits in the public plan. The supplemental doesn't provide additional health benefits. And the robust co-pays, don't actually exist for most people in France, the supplemental coverage gets rid of them.

Conversely, we could outlaw coverage of statins, which would save some money, but kill a lot of folks.

There might be other good examples, but there's actually not very much evidence that statins work:

http://www.alternet.org/healthwellness/78554/?page=entire

jd,

You seem to be very confused. The French system is unsustainable because it is chronically in deficit. This isn't a temporary condition, it is a permanent, structural problem of their system. Spending has exceeded revenues EVERY YEAR FOR 22 YEARS, and it's getting worse. It simply cannot go on like this. The French will either have to cut their health care services dramatically, increase taxes and fees dramatically, or both. A similar problem afflicts Medicare in the U.S.

This kind of fiscal problem is common to health care systems that rely primarily on public funding. Governments are no better at matching supply and demand for health care than for anything else. In contrast, in the U.S., where health care is primarily funded privately, revenues can grow to meet the consumption demands of the market. Countries with health care systems dominated by public funding, including Britain, France and Canada, are increasingly moving towards private funding. This trend is certain to continue as their governments find it increasingly difficult to pay for all the new drugs and tests and surgeries through public funding.

wisewon,

Clearly, the French system is in better shape than ours overall.

Huh? How is this "clear?" The French system is, in the words of its own government commission, on the verge of collapse.

The basic problem with Ezra and other admirers of the French health care system is that they look only at consumption indicators--No waiting lists!--and ignore the fact that the funding mechanism for the system is fundamentally broken and unsustainable.

First, wisewon is correct on the following, end of story:

"But please let's not lose sight of the primary point I was trying to make. France is known as a "hybrid" giving the private market a role in providing people more than a "one size fits all approach." The details suggest otherwise. The benefits are pretty much the same for everyone, the supplementals provide further financial protection. That's a very different picture. That's still pretty much single-payer."

Next, Jason et al, but primarily Jason:

The French system is in chronic deficit? Quel surprise. That hardly means that it is going to collapse, no matter what anyone says. That is politically impossible. If the French have to up the taxes for their healthcare system, trust me, they will. Otherwise the politicians will be out of a job. It's called priorities, boys and girls.

Would that our voters would roust the politicians from office for spending $2-$3 trillion on a useless war rather than on healthcare and even a few undeserving earmarks.

But the more important point is that the French system is in deficit by $14-$15 billion for a system that offers high quality universal care for 65 or so million people.

BFD, as they say.

Our $2.1 trillion annual healthcare system, even including Medicare to date, manages to stay basically in the black by, among other things, simply lopping off 47 or so million – and rising – people from insurance coverage.

Oh my, what a way to balance your books!

I have a dragon devouring a Republican tattoo, myself . . .

Universal coverage is always going to look expensive on paper, and almost by definition it will operate at deficit because the point is that the government is supporting it through subsidy. Nothing says that universal healthcare has to run at a profit though, because its not a 'closed system'. The benefits are to the health and activity levels of a population, meaning that improvements in quality of living and productivity are the true goals. If you want the social argument, it's nice to know that if something goes wrong there's nothing to worry about. If you want the economic argument, then the sooner something is treated effectively, the sooner a person returns to full productivity.

Certainly some national healthcare systems could be considered to be 'in trouble', but one could argue that the US' user pay system is at similar levels of crisis, and without the benefit of providing a real safety net. There is a delicate balance in acheiving cost effective care, and you will find no two universal systems are really the same in dealing with this.

Further, I think it is a specious to give a blanket declaration that a universal healthcare system is unsustainable, unless it is consuming such a huge proportion of the tax base that it is responsible for most of a nation's budget deficit. If you have to run a deficit JUST to have universal coverage, then obviously it cannot be sustained. This should be true of ANY part of a nation's budget, so I've never understood why healthcare should be singled out over anything else.

Some might argue that a system that seeks to 'increase revenue' to cover inceasing costs, inevitably leads to a breakdown as eventually the efforts to impose higher prices will gradually remove people from the system. This is in fact a recipe for real collapse, a healthcare system that fails to cover the people who need healthcare. If a system maintains its solvency by systematically cutting the population off to maintain viability, that is the definition of unsustainable.

It is true that many countries are gradually moving to involve more private interests in their healthcare options. I personally think the true savings are dubious at best, but that's not really what this is about. However, it should be noted that this increase in private involvement can come at a heavy cost too, in Australia for instance large subsidies are needed to keep private insurance companies rolling in profits... to overcome the lack of ability to simply refuse paying out claims. This is with a parallel private hospital system.

At the end of the day the costs of a healthcare system are still going to be there, private or public. They don't magically disappear, they simply get paid via a different means. This argument comes down to a disconnect on a deeper level as to whether healthcare is seen as an essential service or a market. If you believe it is an essential service, there is no amount of cost-benefit analysis that is going to convince you that the answer lies in the private sector. Similarly, if you look at it as a market, then the idea of the entire system being running at a loss is going to be abhorrent.