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  • health care in France

    saw this linked off NakedCapitalism

    http://nihoncassandra.blogspot.com/2...ng-part-2.html

    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....

  • #2
    Re: health care in France

    The real question for the US is not between "socialized" healthcare or "free market" healthcare but how to unwind the terrific mess that is the US medical care industry, what the article describes as "Byzantine" and unable to be intentionally replicated.

    It is all but undeniable that the "healthcare system" in the US is a textbook example of the Law of Unintended Consequences and of government failures (with a few market failures, if you believe in them). But how do we get from where we are to any better situation? Any solution must be (a) politically feasible, (b) work to undo the damage done to the healthcare market over the decades, and (c) not create even more, but different, damage to that same market in the process. The "Single Payer" and "Universal Healthcare" crowd fail to provide a solution that is even close to meeting the first criterion, just as the "True Free Marketers" do. What middle ground can be reached when the interests of the people clash with the interests of the powerful and connected?

    I predict that there will be no progress towards "healthcare reform" that meets all three criteria unless and until the politics in this country begin to embrace personal and economic freedom significantly more than they do now--that is to say, when "both" or all sides can agree that personal and economic freedom are genuinely good things, and that affronts against them are generally bad.

    Comment


    • #3
      Re: health care in France

      Originally posted by Ghent12
      The "Single Payer" and "Universal Healthcare" crowd fail to provide a solution that is even close to meeting the first criterion, just as the "True Free Marketers" do. What middle ground can be reached when the interests of the people clash with the interests of the powerful and connected?
      The only path out is for a government funded health provider to provide the comparison and alternative to the private health insurance and/or health providers.

      With the exception of Canada and perhaps one or two other nations, every other 1st or 2nd world nation has government funded health providers.

      The public options in every case are slower, poorer service, longer waits, etc etc but are cheap. In many cases the same doctors also have private practices.

      But having the transparency on cost as well as an always available and affordable option keeps the private providers honest, while the service and capability of private care is also available for those who wish to pay more.

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      • #4
        Re: health care in France

        exactly, i was arguing this point during obama care. Lets just peel the onion back a few layers and see where the system stablizes. I would like to see any insurance company write any policy with any inclusions or exclusions they want, limit malpractice, untangle the insurance from employment, have an enforceable upfront cost on standard procedures, and see where things settle out. In a few years if things are getting better, lets peel back the onion a few more layers.

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        • #5
          Re: health care in France

          Originally posted by Ghent12 View Post
          It is all but undeniable that the "healthcare system" in the US is a textbook example of the Law of Unintended Consequences and of government failures (with a few market failures, if you believe in them).
          All but undeniable to you maybe. Not to me, nor to economists who've actually studied health care. If you care to educate yourself:

          http://www.economist.com/node/21518818

          The academic literature goes back to post-WWII with Kenneth Arrow's seminal work:
          http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

          If you would like a summary of Arrow's work:
          http://krugman.blogs.nytimes.com/200...re-healthcare/

          (BTW: I am not looking for a "debate"; I've done that with you before. Read if you want to learn -- though I'm guessing you'd rather just have a libertarian circle-jerk.)

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          • #6
            Re: health care in France

            Munger, don't bring arguments if you don't want a debate. In spite of what you believe, I have read up quite a bit on many subjects and have enhanced my understanding of many aspects of this social, political, and economic problem.

            I've heard the uncertainty argument before and it remains unconvincing. The uncertainty and welfare aspect is just one set among many sets of aspects with regards to the real cost of healthcare, because much of the same arguments can be applied to repair plumbing & HVAC, automotive corrective maintenance, and indeed anything relatively costly that occurs regularly at large but rarely to an individual. Sure some of this risk should be insured against, but there is no reason why health insurance should cover an uncompounded broken arm because there is no reason it should cost thousands of dollars to x-ray and cast it. It is the health insurance providers, the beast fed by tax-exempt product status for decades, that is responsible for the burgeoning costs because they are in charge--not the consumers. And their existence as an enormous political force is attributable directly to government intervention in the medical care market. They were, at one point, not so large and in charge.

            What seems to be missing from the list you provided and from similar arguments I've seen is a rigorous analysis of many more factors, such as the numerous government intervention in the medical care markets. Paul Krugman goes on a rant about insurers and HMO's, but ignores history. It may or may not be true that the only utilitarian way out now is to introduce some cheap public competitor, but that isn't certain.

            Just answer this before you return to your smug self-assured stance: where did these medical insurers come from? Why is it such an enormous industry now compared to five or six decades ago? The monster called "US Healthcare" is a result almost entirely from government intervention in response to political forces. It didn't even resemble its current state a few generations ago.


            As an analogous thought experiment, think of the long-term consequences of the following policy: the federal government will allow employers to compensate employees as usual, or can give their employees tax-exempt, all-inclusive automotive insurance.
            Last edited by Ghent12; July 25, 2011, 04:18 PM.

            Comment


            • #7
              Re: health care in France





              Comment


              • #8
                Re: health care in France

                Originally posted by Ghent12
                It may or may not be true that the only utilitarian way out now is to introduce some cheap public competitor, but that isn't certain.
                The problem with health care is that ultimately it has so many different economic monopoly chokepoints.

                Drug development, hospitals/surgery, chronic medical needs, extreme medicine (i.e. organ transplants), the list goes on and on.

                While I do not think government can create the best possible health care option - the issue isn't the best possible health care possible.

                It is the most economic for the most people. In this sense it is very much a public utility: it isn't that getting all your water via bottles isn't more optimal - if you can afford it - it is that providing potable water for your entire population is a public good.

                And whatever you want to say about government services - whether it is vehicle registration, property tax collection, etc etc - the workers may be less motivated, work less hard, etc but they aren't out to screw you out of a dollar.

                As I've noted before: we don't even have to build from scratch. The US federal government already operates a 50 state health care provider network via the Veteran's Administration. There are any number of ways by which the efficacy of this network can be tested - including requiring all those newly insured via the "No Health Care Insurance Company Left Behind" act to first have to go through the new federal health clinics.

                As for the health insurance side - the economic distortion there is gigantic. There simply is no easy way to transition from the existing employer subsidized health insurance to fully private individual health insurance - especially if the health care provider cost side isn't tamed first.

                That's why IMO the first step must be a public option for health care services. Insurance can come later.

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                • #9
                  Re: health care in France

                  Ah, U.S. healthcare in the 21st century...

                  Doc: "So you say you've been irregular lately."
                  Patient: "Yes, sir."
                  Doc: "Well, I was going to tell you to eat more fiber and give you some magnesium citrate, but we'd better run you through the MRI machine a few times just to be sure it's not bowl cancer."
                  Patient: "You don't think it's cancer, do you?"
                  Doc: "No, but we'd better make sure."



                  Patient: "Thank God we have the best healthcare in the world."
                  Doc: "Yup, you might have been in Canada where you wouldn't get this MRI. Your insurance company will spare no expense to keep you well."
                  Patient: "Boy it's a shame that Canada can't afford this quality care."
                  Doc: "Sure is. They just don't spend the money we do."





                  Patient: "Doc, you mean to tell me that if Canada spent what we did it could have almost 350,000 more nurses on staff?"
                  Doc: "Absolutely."
                  Patient: "Or they could have over 5,000 MRI machines instead."
                  Doc: "Yup."
                  Patient: "Does that mean that an MRI machine is worth 70 nurses or 18 doctors?"
                  Doc: "Let's move on, we're ready to get you in the machine."





                  Doc: "See, nothing to it."
                  Patient: "How does it look."
                  Doc: "Ah, you're fine."
                  Patient: "Thank God!"
                  Doc: "I'm going to put you on Nexium, though, just to make sure there's no more stomach trouble. Here's the script."
                  Patient: "Thank you, I saw this on T.V."
                  Doc: "See you next time."

                  Comment


                  • #10
                    Re: health care in France

                    Originally posted by Munger View Post




                    don't they count infant deaths differently, and with all the factors that go into life expectancy of a nation, how could this possibly be well correlated with what type of payment system they have for health care?

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                    • #11
                      Re: health care in France

                      Originally posted by mikedev10 View Post
                      don't they count infant deaths differently, and with all the factors that go into life expectancy of a nation, how could this possibly be well correlated with what type of payment system they have for health care?
                      yes many count infant deaths different than we do which accounts for much of if not more than the difference in infant mortality

                      Comment


                      • #12
                        Re: health care in France

                        http://www.standard.net/topics/opini...varies-country

                        In response to Mr Cisney's letter concerning the quality of healthcare in America vs. the cost, one of the comparisons he used was the infant mortality rate in America versus that in other developed countries. The infant mortality rate in the USA is 6.3 deaths per 1000 live births while the lowest reported is approximately 2.3 deaths per live births. In the United States, however, we count any infant exhibiting any sign of life as alive, no matter the month of gestation or the size of the fetus. In other European countries, they define the month of gestation and the size of the fetus before they count it as a live birth. For example, in France, Czech Republic, Ireland, Netherlands and Poland, the fetus must be at least 22 weeks and/or weigh 500 grams, if not, it is not a live birth and not counted as a part of the infant mortality rate. Another challenge to comparability is the practice of counting frail or premature infants who die before the normal due date as miscarriages or those who die during or immediately after childbirth as stillborn. Therefore, the quality of a country's documentation of prenatal mortality can matter greatly to the accuracy of its infant mortality statistics. This point is reinforced by the high ratios of reported stillbirths to infant deaths in Hong Kong and Japan in the first 24 hours after birth, a pattern that is consistent with the high recorded sex ratios at birth in those countries and suggests that many female infants who die in the first 24 hours are misreported as stillbirths rather than infant deaths.
                        So, not all statistical information is formulated in the same manner and to say that the quality of our healthcare lags that of other developed countries is misleading and requires a more detailed analysis to ensure we are comparing apples to apples.

                        jim

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                        • #13
                          Re: health care in France

                          Life expectancy as a measure of health care? Give me a break.... Subtract out the personal lifestyle choices that lead to early, excess mortality (including drunk driving, drug abuse, tobacco abuse, morbid obesity and its health care considerations, sedentary lifestyle, gang banging, lack of prenatal health care despite being freely available in every state) and maybe life expectancy would be an accurate measure of health care efficiency.

                          Comment


                          • #14
                            Re: health care in France

                            Originally posted by Munger View Post
                            statistics...
                            "There are Lies, Damn Lies, and Statistics." -- popularized by Mark Twain

                            As others have pointed out, the statistics attempting to compare the United States to other nations are disingenuous because the statistics were not gathered the same way. It's attempting to compare kilometers to dollars.

                            The U.S. "healthcare system" has its share of flaws, including but not limited to the industrialization of child-birth (if you want a "natural birth" with the assistance of a midwife in the US, you are a wacko and no health plan will cover you despite its many advantages to C-section factory births in hospitals), the many noted problems with the current oligopoly of current private health insurance firms, and so forth. However, one thing you cannot really claim is that the U.S. has a "bad" system from the perspective of actually providing care so long as you aren't priced out of what you need.

                            All healthcare is rationed because it is scarce in quantity. The question is the method used to ration--in "free healthcare" places they ration mostly according to edicts and timetables. Here in America it's a combination of price and edicts, though a few are by time out of necessity (organ transplant, etc.). However the real problem with American health care is that the consumers of the actual care are left out of the price loop almost completely. It has been transferred into the hands of a third party which ostensibly at one point provided a necessary service, but now has become a monstrosity. I am speaking, of course, of the various private insurance providers that exert enormous control over the market of health care. This is the market equilibrium point right now because of how the market was cultivated and allowed to develop. If we want to remove their influence and return the market to a place where consumers influence it more (meaning constant pressure for lower prices and higher quantities), then we have to think of a way out of this situation that meets the criteria I listed above. Unfortunately, with Obamacare we went in the opposite direction of a more desirable outcome. Hopefully we will learn, collectively, from policy failure and politically enable politicians to do the actual right thing.

                            Comment


                            • #15
                              Re: health care in France

                              Originally posted by Ghent12 View Post
                              "There are Lies, Damn Lies, and Statistics." -- popularized by Mark Twain

                              As others have pointed out, the statistics attempting to compare the United States to other nations are disingenuous because the statistics were not gathered the same way. It's attempting to compare kilometers to dollars.

                              The U.S. "healthcare system" has its share of flaws, including but not limited to the industrialization of child-birth (if you want a "natural birth" with the assistance of a midwife in the US, you are a wacko and no health plan will cover you despite its many advantages to C-section factory births in hospitals), the many noted problems with the current oligopoly of current private health insurance firms, and so forth. However, one thing you cannot really claim is that the U.S. has a "bad" system from the perspective of actually providing care so long as you aren't priced out of what you need.

                              All healthcare is rationed because it is scarce in quantity. The question is the method used to ration--in "free healthcare" places they ration mostly according to edicts and timetables. Here in America it's a combination of price and edicts, though a few are by time out of necessity (organ transplant, etc.). However the real problem with American health care is that the consumers of the actual care are left out of the price loop almost completely. It has been transferred into the hands of a third party which ostensibly at one point provided a necessary service, but now has become a monstrosity. I am speaking, of course, of the various private insurance providers that exert enormous control over the market of health care. This is the market equilibrium point right now because of how the market was cultivated and allowed to develop. If we want to remove their influence and return the market to a place where consumers influence it more (meaning constant pressure for lower prices and higher quantities), then we have to think of a way out of this situation that meets the criteria I listed above. Unfortunately, with Obamacare we went in the opposite direction of a more desirable outcome. Hopefully we will learn, collectively, from policy failure and politically enable politicians to do the actual right thing.
                              Actually mid wives are not more common in hospitals than you might think. Insurance now covers CNM in most cases. Here is one link
                              http://www.babycenter.com/0_choosing..._322.bc?page=3
                              Will my health insurance cover a midwife's services?

                              Many U.S. insurance plans, including Medicaid, cover CNM services. In fact, Medicaid reimbursement for CNM care is mandatory in all 50 states, and 32 of the states require other insurance plans (including HMOs) that provide coverage for pregnancy to allow women to choose a nurse-midwife as their pregnancy care provider. (Another seven states have laws mandating coverage for "any willing provider" a woman chooses, which would include CNMs.)

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