Jonathan Cohn makes the case. The one thing I would say is that it seems weird to me to ignore distributive issues when writing about this issue, especially from the pro side of the universal health care debate. Given that the United States is substantially richer than France and has a substantially less egalitarian distribution of wealth and income than does France, it would be shocking to me if you couldn't find some Americans who have better health care than do most French people.
« Kirkpatrick Again | Main | Here's an Idea... »
French Health Care Is Awesome
10 Apr 2007 10:48 am
Comments (40)
Is America really much less egalitarian than France? I know it would seem to be true, but I'm less sure if statistics would confirm this.
The problem with comparisons to health care France is that it is a much smaller country with a generally greater population density (about 3 times more dense than the U.S.). Throw in a much more centrally organized government as compared to the U.S., and you have a system that is tailored to much different problems of logistics than the United States.
The only real model worth comparing to the United States is Canada, because only Canada has similar issues in the logistics of delivering health care (large country, low population density, less centralized government). And the quality of routine care in the Canadian system is, on balance, worse than that of the United States (better in some ways, worse than others, but access and speed of delivery of basic services is generally worse)--and that's not even taking into account that the U.S. virtually subsidizes part of Canada's health care system as a consequence of Canadian price controls on pharmaceuticals.
The issue "The problem with comparisons to health care France is that it is a much smaller country with a generally greater population density (about 3 times more dense than the U.S.)," gets brought up whenever anyone talks about learning from a practice in another country that is smaller (France, Denmark, the UK, Ireland, Japan, Korea, etc.). However, the Canadian example is also fraught with problems: it has a much lower population than the US residing within a larger geographical space with most of the country living within 50 miles of the US border. Since we have states, we could, for instance, possibly copy what the French healthcare system does right on the state level and have on the national level the laws and institutions that would allow Americans participating in the program to take their healthcare coverage from state to state without all the red tape (at least less compared to the current private insurance red tape).
Alex, on what basis do you assert that population density is the key issue in what countries we can compare the United States to? This appears to be an a priori assumption, rather than a case you have actually made. Canada, I would note, is far less densely populated than the US - the United States is ten times more densely populated than Canada. So I call bullshit on your whole argument, which amounts to unsupported cherry-picking.
It's not actually about buying your way out of the system. Healthcare needs a massive infrastructure to work properly. For the mega-rich, pretty much any country can create this infrastructure and they all do, and it looks pretty much the same. Mega-wealthy almost always buy out of these systems.
However, only a tiny handful of people anywhere are the mega-wealthy. The question of how healthcare is provided to the upper classes, the professional class, and the upper middle class is what you're really talking about. And there's a big difference between how it's provided in France and in the US. In France, you're going ot easily get all kinds of preventive and supportive care that you don't get here b/c we lack such infrastructure. You're also not going to worry in France about your healthcare bankrupting you, a concern for all but the mega-wealthy in the US. Less of a concern for the US upper classes, because they are likely to have dotted all the i's and crossed all the t's to get proper coverage.
While it's true that Canada has a smaller population density on paper, given that most of Canada (ie a substantial portion of the northern half) is sparsely populated or not populated at all. The portions that are populated are comparable to the population density of the United States.
Population density comparisons are signficant because of the primary problems with the U.S. system, apart from the nightmare insurance system we have, is that we face a severe shortage of nurses and doctors (the U.S. ranks among the lowest of all industrialized nations for doctors per capita). This not only affects access to quality care, it affects the cost of such care, as well (law of supply and demand). With a denser population, it's possible to get by with fewer doctors and nurses and have decent access to care, because you can concentrate those doctors and nurses. When a population is more spread out, more doctors are necessary, given the simple logistics of people not wanting to drive four hours to get to a doctor.
Additionally, a more spread out population in a greater geographic area also affects the availability and cost of the infrastructure necessary to support higher quality health care.
As far as I have been able to determine, NOBODY has tried to figure out or develop any substantive policy drawn towards providing incentives for more people to become doctors and nurses. Unless the doctor and nursing shortage is dealt with, no health care plan will actually improve the status quo.
Alex, I really think your population density argument is bogus. Just like in Canada, the vast majority of people in the US live in relatively densely populated areas. Only in very sparsely populated areas would it be true that you need more doctors per capita.
Matt, have you seen Jonah Goldberg's contribution to the debate?
Oh man...
Jonah writes: "Maybe, just maybe, France and Denmark can handle the systems they have because they have long traditions of sucking-up to the state and throne?"
Sucking up to the throne? France??? Seriously, WTF.
cs,
I think that the U.S. is more dispersed than Canada--offhand I can't find numbers, but given issues of suburban sprawl and everything else I'd say we definitely must be more diffuse than France.
And I really do think that part of the root of health care crisis that needs to be fixed is to figure out how to deal with our shortage of doctors and nurses and what policies can be put into place to alleviate this problem.
I admit that I am extremely skeptical about a system of government-run health care, or even a single payer system. That said, I'm not going to pretend that the U.S. has a great system, because we don't--it pretty much sucks. But I think that there's a great deal of room for more market-oriented reforms coupled with some safety nets to assist the poor and children that would be a better solution than a single payer system.
Sorry, Alex Kanpp's arguments don't make sense, and I say this as someone who works on Health Policy and population density.
First, a great many areas that are densely populated lack docs. It has more to do with wealth than density, though that definitely correlates in many areas.
Second, most of the population is clustered in coastal states and a few states in the midwest. The ten most populous states (California, Texas, New York, Florida, Illinois, Pennsylvania, Ohio, Michigan, New Jersey, Georgia) had 54% of the total USA population and 75% live in the 20 most populous states. The 20 least populous states have only about 11% of the population but make up 50% of the land area of the country.
Third, the US doesn't currently lack all that many docs or nurses. The major problem is that we have a surfeit of specialists and a lack of primary care docs. Most (all?) other countries have a higher proportion of GPs vs. specialists. The US turns out lots of specialists and few GPs.
We know how to change that. Pay GPs more and specialists less.
By the way, Canada also has problems getting practitioners into sparsely populated areas.
JP:
I think Jonah meant "France and Denmark ...have long traditions of sucking-up to the state and throne RESPECTIVELY" (in reference to France's superstatist structure and Denmark's being the 2nd most senior monarchy in the world)
"Given that the United States is substantially richer than France..."
Really? Leftists actually admit this?
Sk
Shortage of nurses and doctors? I would think that raising nurses salaries would help the one problem (as opposed to our current practice of importing cheap labor from abroad.) The other would require busting one of unions that the Republican Party really likes.
As for pharma subsidies: we subsidize the world from research to retail. I can handle the former, the latter is just wrong, at least with regards to the rest of the first world. It would be an interesting experiment to peg the cost of just one drug to the Canadian level and see what would happen. Would pharma pull it off the market world wide now that it had no 'subsidy'?
Sk,
Implying that Matthew Yglesias is a 'Leftist' is amusing.
Clearly, in absolute terms the US is MUCH richer -- it has many more people.
Also, the US works much harder than the French, and so we have a good deal more production per person.
As for living standards, if you count free time, the proper metric would most likely be productivity per hour, which, I think puts the French slightly ahead of us, although I that result is arguable enough as to call it a wash.
"Third, the US doesn't currently lack all that many docs or nurses. The major problem is that we have a surfeit of specialists and a lack of primary care docs. Most (all?) other countries have a higher proportion of GPs vs. specialists. The US turns out lots of specialists and few GPs."
What are you counting as GPs? Is internal medicine a specialty or a GP? Most of the good primary care physicians do specialize, they just special in internal medicine.
I think that SteveH's comments above miss the mark. He says:
1. Lots of densely populated areas lack doctors.
2. Much of the US's population is concentrated in a few states.
...Therefor, the US's lower population density doesn't matter with respect to copying a European nation's healthcare system?
I don't get how that follows.
The argument is this: Regardless of the fact that, say, Colorado or Nebraska may not have a lot of people compared to New York City or LA, we don't get to write them off and not provide healthcare for them. And they aren't willing to travel to one of the coasts to get their healthcare, either.
So you end up building infrastructure and employing people to serve a certain geographic area, and you can't scale everything down to match the population in that area, either. You can have a small number of beds in the hospital, but you probably need to have an MRI there, even if it stands idle 75% of the time while the same machine in an LA hospital is booked 'round the clock. Tough luck, because you can't buy 25% of an MRI, and you don't get to tell rural people that they need to take a plane trip or a six hour drive if they need to see if the knock on the head they took is giving them an aneurysm.
(Or whatever -- some medical professional can substitute in examples which make sense. I'm not a doctor.)
Now, I don't know how much this matters. Maybe 95% of the costs of healthcare are very scaleable, so our lower population density than France's won't do much more than tack on a couple of percentage points to the costs. Or maybe it's huge, and wholly explains the difference between the US's healthcare system and France's. I don't know, and, to pre-empt the next few commenters, I don't think that anyone's gut guess is probably very reliable. It's something that I'd be interested in seeing a study on and some hard data for.
"What are you counting as GPs? Is internal medicine a specialty or a GP? Most of the good primary care physicians do specialize, they just special in internal medicine."
Yes, internists are considered primary care providers. I think about 33-35% of practicing docs are considered primary care providers in the US.
"Therefor, the US's lower population density doesn't matter with respect to copying a European nation's healthcare system?"
Not a whole lot. Eighty percent of the US population lives in Metropolitan areas. The 20% that doesn't isn't causing the massive difference in costs you see between every other OECD country's health costs and the USA's costs.
For that matter, not every hospital needs an MRI and we have an overabundance of that kind of technology in the US, and that does drive increased costs. (And the fact is that people in rural areas do have to take the bus or drive long distances to get the same kind of services people take for granted in urban areas.)
I'm probably not being clear, so let me try again: In much of the US population density is similar to Europe or OECD countries. In US areas with high density, and lots of providers, you do not find lower health care costs. Usually utilization and costs are higher in high density areas vs. low density areas.
Population density of the US vs. Europe has nothing to do with our higher costs. We do not spend lots of money in this country to provide services in remote low density areas. We simply spend a lot more for services that are provided.
Shorter Johnathan Cohn: the US cures too many cancers. We would be much better off if we just let people live with their cancer, as Europe does.
Can the Democrats please run on that platform?
Maybe there is one problem we can get the Democrats to help fix: we pay doctors WAAAAAY too much. In France, they are paid something like ~$50,000 a year. Anything you folks can do to cut the salary of every single doctor in America by 2/3?
"The other would require busting one of unions that the Republican Party really likes."
If you're referring to the AMA, I'd call it a guild, not a union.
Responding to a number of comments by SteveH:
Not a whole lot. Eighty percent of the US population lives in Metropolitan areas. The 20% that doesn't isn't causing the massive difference in costs you see between every other OECD country's health costs and the USA's costs.
Do you have evidence for this assertion?
For that matter, not every hospital needs an MRI and we have an overabundance of that kind of technology in the US, and that does drive increased costs. (And the fact is that people in rural areas do have to take the bus or drive long distances to get the same kind of services people take for granted in urban areas.)
I think that "we'll cut back on the medical services available to people who don't live in cities" is going to be a tough political sell. I think it also undermines the moral high ground that I think that most universal health care advocates are trying for.
I'm probably not being clear, so let me try again: In much of the US population density is similar to Europe or OECD countries. In US areas with high density, and lots of providers, you do not find lower health care costs. Usually utilization and costs are higher in high density areas vs. low density areas.
Okay, that's a good argument, but it needs some developing. So, say that an MRI costs $1,000 at busy urban hospital where the machine is fully utilized, and $1,000 at sleepy rural hospital where the machine mostly sits idle. Is that because the true costs of both uses of the machine are the same, or is it because, say, the insurance companies that those hospitals deal with have said "We'll pay $X for an MRI scan, regardless of where it is"? In that case, the same apparent costs regardless of location could effectively be the profitable urban area subsidizing the unprofitable rural area. That kind of thing happens all the time in other industries.
It's not that I find the argument that you're making terribly implausible -- I wouldn't be surprised to find that population density doesn't have much to do with costs. It's that I think that figuring out this kind of information is tough. You can't glance at a few figures and really understand how the money works in any kind of complicated industry. That's why I'd like to see a real study on the subject.
"Given that the United States is substantially richer than France..."
Really? Leftists actually admit this?
Sk
Generalization without attribution. My favorite.
Name a single (1) prominent "Leftist" who argues that France is richer than the United States, please. (One whose first name isn't "Straw" and whose last name isn't "Man".)
And what on Earth does that prove? That France isn't "better" than the US? I find judging the quality of life of a nation's people based on how wealthy they are to be very suspect. And, what-- liberals are constantly running around trying to find ways to demonstrate France's superiority to the US? Who? Where?
And the quality of routine care in the Canadian system is, on balance, worse than that of the United States (better in some ways, worse than others, but access and speed of delivery of basic services is generally worse)--and that's not even taking into account that the U.S. virtually subsidizes part of Canada's health care system as a consequence of Canadian price controls on pharmaceuticals.
I'm sure that comforts the 47 million Americans with no health insurance whatsoever no end.
Michael B Sullivan - Since SteveH was responding to Alex Knapp's claim that Europe and the USA were simply not comparable because of the differences in population density, and that we could only compare the US to Canada, I don't feel that the burden of proof falls entirely on him.
It'd be interesting to see how much medical expense is due to technology and drugs. Then try to determine what proportion of technology and drugs is produced because of the American medical market. Then try to determine how much technology and drugs wouldn't be developed because we went to a system such as in France. Essentially, are foreign countries free-riding on the American medical system?
Matt Y -
on what basis are you claiming that France is both "substantially" poorer and "substantially" more egalitarian than the U.S.? the statistics dispute the former (World Bank had both in the top 15 richest countries in per capita GDP in 2004), and i'm sure the rioting Muslim youth in France (with unemployment near 40% in some areas) would disagree with the latter (as would the World Bank, which said in 2002 that the richest 20% of Americans have about 46% of national income, while in France they have 40%. a difference, sure, but i don't think it's especially "substantial").
a quick perusal of nationmaster.com or any other statistical database disputes your premise. so i ask: upon what basis are you drawing your conclusions? i don't usually find your posts to contain misinformation, but i think this one qualifies.
anyways, the notion that everyone in France has better health care than everyone in the U.S. is simply laughable. despite all the hysteria over drugs in this country, according to the WHO, more Americans had access to "essential" drugs in 2000 than did the French (both were near the top of the worldwide distribution). the U.S. spends more *public* dollars per capita on health care than does the French, with almost all of that going to the elderly, the poor, or children. i know that simply spending money doesn't necessarily mean good health care outcomes, but it does designate the levels of social commitment. certainly, there are aspects of the French system which are better than ours. that system works pretty well for the French, although how well it would translate to the U.S. is debatable. but it is simply incorrect to state that - across the board, with zero exceptions - the French system would be better for all Americans if implemented here.
Barbar - Look, I'm not here to win a debate. This isn't a courtroom, and I don't know that the "burden of proof," if that phrase even really makes sense outside of a courtroom, falls on anyone.
I think that this would be useful information to have for anyone who's trying to develop a nuanced understanding of healthcare. If SteveH can point me at a study that says he's right, then awesome. If he can't, I'm not saying that he's wrong... I'm just saying that I feel I'm missing an important piece of information.
I won't argue with that, facts are good. Just pointing out the context of the quoted passages.
As to statistical evidence of France's greater equality, the standard measure is the Gini coefficient - You can see from the link that France has a substantially more equal distribution of income that the US - although that has not always been the case.
http://en.wikipedia.org/wiki/Image:Gini_since_WWII.gif
That 40% vs 46% statistic sounds like a cherry-picked number. As to anecdotal evidence like the French rioters - you will never see the kind of third world conditions in France (not even its departments in the Caribbean) that we saw in NOLA in the wake of Katrina.
And the quality of routine care in the Canadian system is, on balance, worse than that of the United States
Oh, cool misdirection. "routine care", "on balance". They pay less, they live longer, they have lower infant mortality, and spend a larger fraction of their larger lives in good health, and they cover more of their population. It's a real stretch to call that "on balance, worse".
The same can be said of about 20 other first-world countries. On balance, our system sucks immensely.
The US is "substantially richer" than France?
"Not a whole lot. Eighty percent of the US population lives in Metropolitan areas. The 20% that doesn't isn't causing the massive difference in costs you see between every other OECD country's health costs and the USA's costs."
Do you have evidence for this assertion?
Yeah, strangely enough I do. It isn’t online but Chapter 6 of Rural Health in the United States states that “Overall, the Medicare program pays less per rural than per urban beneficiary, and pays less for the same service provided in rural than in urban places.” Not only that, the rural population is far more likely to be uninsured. See Rural Residents More Likely to Be Underinsured, and as we all should know the uninsured are less likely to get care than the insured. Rural residents are generally poorer than urban residents as well. It all adds up and rural people aren't breaking the health care bank.
I think that "we'll cut back on the medical services available to people who don't live in cities" is going to be a tough political sell. I think it also undermines the moral high ground that I think that most universal health care advocates are trying for.
I'm not talking about what the way things should be, I'm talking about the way things are. (And there are economies of scale that mean that certain services aren't going to be available in low density areas. Hospitals that perform large volumes of high-complexity procedures have better outcomes. You don't want isolated hospitals doing open heart surgery infrequently because they're not going to be good at it.) On the contrary, I'd argue that more services should be available in rural areas than currently are, but wishing won't make it so and you have to start where you are.
But, to get back to the main point in this thread, care is reasonably good by any standard in Germany, France, Canada, or most industrialized countries that manage to cover all their citizens with universal health care. The US is not such an outlier that it couldn't do the same, especially since we're the richest country in history. We can't provide every kind of service to every citizen no matter where they live, but we could provide services to every citizen if we wanted to, certainly at no higher overall costs to the country than we pay now.
Should have included these figures in the post above:
Average payment per rural Medicare beneficiary was $4477 in 1995.
Average payment per urban Medicare beneficiary was $5487 in 1995, or about 22% more than the rural bene. And that doesn't mean $ spent in rural areas, that's $ spent on benes who live in rural areas.
Source is the Rural Health book.
S. Weil -
yes, i'm well aware of the Gini coefficient (i'm an economist currently doing research on income distribution). but Gini is only one measure, and is certainly not without flaws. actually, wikipedia's description of some of Gini's short-comings is pretty good.
one the biggest is this: Gini is a general measure prone to miscalculations caused by measurement errors. when we measure inequalities in the U.S. and France using only income calculations, we aren't measuring the same thing. we're measure two different things, since market incomes (pre-tax and pre-transfer, excluding capital gains or noncash transfers) do not accurately represent how equal a society's income distribution is. in addition, the Gini is not terribly reliable for comparing two countries which are so far apart in size of population, geography, etc.
plus, the U.S. has gone through several major tax changes in the past 20 years (1986, 1991, 1993, 1997, 2001, 2003, etc.). each of these changes will have fairly dramatic effects on the Gini coefficient, even if actual distribution remains unchanged. as marginal tax rates in the U.S. have declined, it would have been nearly impossible for the Gini to have stayed constant, but other measures - such as consumption data, measures of wealth inequality, compositional changes which affect measurement, social mobility measures, business cycle changes, etc. - almost all show that inequality hasn't really changed that much in the U.S. in the past two generations.
and yeah, picking the 40% and 46% was cherry-picking, i guess. but i was commenting on a blog; no time to write a book. my main point was that the broader measures of inequality show that the U.S. and France isn't that different. in addition, the U.S. has about half as much unemployment, so those of our poor who are able to get jobs in the U.S. but wouldn't be able to in France (mostly the less-skilled, immigrants, and minorities) are better off here than they would be there.
to sum: there is no basis for saying that France is "substantially" more egalitarian than the U.S.
In Canada, the squeegee kid and the president of the country's
largest corporation have exactly the same access to any needed
medical procedure - once you process that fact, you, the richest
country in the history of the world, should hang your heads in
collective shame.
Steve H
As an economist currently doing research on income distribution - you should have been able to do better than cherry pick a number - who are you working for by the way - It sounds like some right-wing outfit trying to deny the obvious? Of course "substantial" is a term of art and almost all ecomomic data is compromised in some way - so what?
As for the unemployment rate differences, the employment/population ratio in France for prime age workers is essentially the same as the US. Our unemployment rate is lower because we have a higher proportion of people who are in jail, disabled, discouraged or in the military than if France - and thus not counted as part of the labor force. Whether someone in jail or disabled in the US is better off than someone on the dole in France is another subjective question.
S. Weil, I think you've confused me with wkw.
This comment section seems to have petered out, but I'll just add my comments. I live in California now but originally hail from Canada. My mother and sister, still in Canada, recently had a heart attack and a diagnosis of cancer respectively. The care that they received fairly astounded me.
My mother was well taken care of, recovered very well, (she's 85) and not only had regular follow-ups, but one year of cardio-therapy. Her cardiologist recently discovered that her heart was enlarging. Three days later, she was in to see a specialist in Toronto, (granted, she's fortunate to live near such a large metropolitan center) All with not one penny spent by her, all covered under the health care system.
After my sister's cancer diagnosis, she was booked in for treatment at a cancer treatment center, spent 6 weeks there undergoing radiology treatment and was transported to and from the center anytime she wanted to visit family (she lives about an hour away) Again, not one penny out of her pocket, all covered under the healthcare system.
Now, I realize that this is a small empirical sample and might not statistically reflective of the entire system, but everyone in Canada has access to this type of care. Many in America do as well, as long they can pay for it.
Comments closed April 24, 2007.
| 
Heads in the Sand
My family gets fabulous health care. Excellent doctors, excellent hospitals, and no or minimal waiting times for everything. I’m not saying that the U.S. health care system doesn’t have huge problems, but your “some Americans” comment is silly.
Posted by ostap | April 10, 2007 11:04 AM