Wednesday, August 19, 2009

Why French Health Care Works

One of the things that makes our country great is that we have the ability to take things from other cultures, absorb them, shape and market them, and make them our own (look at food, for example; we've got variety coming out every orifice).

So if another country has a sustainable health care system that is delivering good care, why aren't we looking at it?

This was the challenge given to me to justify the obscenity of Obamacare or a single-decider government system. And because the British and Canadians have systems that are approaching collapse, our friends (and dirty frog-eating bastards) in France were held up as the model of an ideal health care system. So I decided to take a look and see what made this system tick. And for clarification, this is not an endorsement of a switch to this system, but merely an attempt to find out what we're doing wrong in our system, which is fixable if we could all understand the concept of individual rights and the proper role of government in maintaining the health care system.

Sustainability - First of all, the system has been functioning with various tweaks since the liberation of the country in 1944 (although the foundations were created before the war). And while I'm going to find some problems, 65 years without obvious major problems (Mediscare began plaguing us in 1965) is quite an achievement. And it points to a system that is currently sustainable, unless some shift changes the prices to such a degree that the system is overwhelmed.

Redistribution - Like any government system, the French system collects taxes based on the ability to pay and then disperses care based on need, redistributing resources to those that can't currently afford them. The vast majority of French citizens agree with this concept. Not so strangely, I don't. But hey, that's their country.

Public vs private -Similar to our current system, there are different levels of care, depending on the ability to pay. Long story short, if you can afford the best, you get the best by paying for it. And the system pays for 80%, with the rest being covered by "gap" insurance (similar to the Mediscare). Otherwise, doctors are tied to some fee schedules, which have been adjusted and tweaked over decades.

Doctors - On the pay scale, doctors make double the average salary, (compared with five times the average salary here. However, they have two advantages. First, tort reform takes the costs of malpractice insurance away, to the extent of actual malpractice. And French doctors don't have to pay for their school. This means no damned loans.

Outcomes - For some in the debate, outcomes are the end-all in measuring the success of a health care system. In this, the French win. I don't have those numbers off the top of my head, but I'm going to concede this point, primarily because numbers don't lie.

Update: Ask a nurse for the numbers, Satyavati will provide:

The Costs - The system was set up with a 16% payroll tax (which funds other social programs), as well as some sin taxes. It's now up to 20%, and resistance is strong against another increase. And that push for an increase is because costs continue to go up. On the plus, the French system can always cut payments and/or ration some care, with the slack being picked up by the gap providers or individuals paying cash. Of other countries with government systems, they are the most expensive, except for us. The per-person price is roughly half half of what we pay for health care.

Referenced links:

Conclusions and wisdom - The reason the French system has worked is because they have retained many of the free market elements that keep our system a sustainable mess, while addressing many of the problems that are creating serious gaps in the treatment of our citizens. However, with the fact that costs are increasing across the board at an accelerated rate (due to many factors, but mostly because there is no incentive to control prices where they aren't already controlled by government fiat) and because of the general conditions of the French culture and economy, the system is either going to shift to even more of a private model or risk unsustainability. And the fastest way for this to happen is to have more modern countries shift toward a government system to try to fix their problems (that would be us). Because while we may have many problems with more routine care, we do have two things that are advantages over the rest of the world: We have the greatest amount of innovation (because there's profit in innovation) and we are the place where the world comes for the most challenging procedures.

No one country has it right yet. And any major change cannot be hurried and have a chance to get it right. I have, previously, laid out the framework for what would fix this (subject to a lot of study and revision). And I'm going to leave it to the comment section now, because there is little more I can add until someone stirs up the shit.


TAO said...

So, if this is true, "Because while we may have many problems with more routine care, we do have two things that are advantages over the rest of the world: We have the greatest amount of innovation (because there's profit in innovation) and we are the place where the world comes for the most challenging procedures."

Then why not nationalize routine care and then allow insurance companies to peddle add on policies (bring the AFLAC model to healthcare) and allow people the option to add additional coverage as they so desire? Oh, my, that would be the Swiss model...

Actually, innovation is pretty much funded by our government through grants and support of research centers....

So, we fund the innovation then corporations get the patent and they go off and make a profit off of it...

Capitalism is brillant isn't it?

Satyavati devi dasi said...

For some in the debate, outcomes are the end-all in measuring the success of a health care system.


The bottom line has to be quality of care. How do you measure quality of care? By outcomes. That has to be your standard. The most expensive system in the world (or the cheapest, for that matter) is just another way to piss away money if you're not getting good outcomes.

Just like if I were to buy the new Jag XK for $83,300... you're damn right it better come fully optioned, more luxurious than my house, and that 'losing-your-virginity' thrill every time you start it up. It better have incredible power, killer acceleration and enough torque to drag the Chrysler building down the street. Because you don't spend $83K on a piece of shit Pacer.

Same thing here. We're paying Bentley prices for healthcare, but all we're getting are last year's Indian Tatas and a couple of Yugos.

Outcomes are the bottom line.

Patrick M said...

Tao: If we were truly capitalist I'd agree with you.

Nevertheless, A model that provided a basic health care, and required paying for the rest would still be an improvement over what the current possible bills are offering.

Saty: That's the point. Psychologically, we're NOT paying for our health care (even though we do spend a whole lot). And while the French pay less, they have a little more sense of the cost of their health care than we do.

So imagine if all of us had to look at the bill, or even better, the prices would be posted on the wall at the doctor's office when we walked in.

The French understand this, and did their damnedest not to let their system become completely single payer.

And outcomes don't mean shit if you create a self-destructing in the process. Because when the system fails, the outcomes go straight to hell with them.

Satyavati devi dasi said...


I really don't think people have this big psychological issue you keep talking about.

We know exactly how much shit is going to cost us, and that's why so many of us don't have it. People who are choosing between medication and rent know how much each of those things cost, and have to make that decision. People who go without their own healthcare so they can take their kid to the dentist know exactly how much that costs. People DO look at the bills, and that's why they know they can't afford it.

The point is, the travesty, the actual issue that chaps my ass about all this, is that so very many Americans are absolutely brainwashed that we have the best care in the world and the whole rest of the world, who, btw, have socialized or somewhat socialized systems, are lingering on the edge of death and clamouring with all their strength for their countries to change over to our system.

This is simply not true. I don't know if it's some psychological leftover from the cold war that anything socialist must necessarily be bad, and that whatever we have here must necessarily be better, but the point is that people believe this to a fanatical level. And they somehow refuse to acknowledge the awful truth of denial of services, recission, preexisting conditions and other exemptions that the insurance industry makes in order to maximize profits at the expense of our collective health. And, even more amazing, these people will not even discuss it with you.

Folks like my mom, who has no one but Medicare to thank for paying for her chemo, radiation, surgery, and for taking care of the equipment and miscellaneous she will need to live the rest of her life, freak out at the mention of 'socialized medicine'. People are screaming that they don't want 'government interference in Medicare'. They don't even realize that Medicare is 'socialized medicine'. The fanatical resistance against any kind of change, without even caring about facts or information, is frightening.

Patrick M said...

Saty: Just because you (and occasionally I) look at the bills to see a number does not mean people honestly understand how much they pay. You see the same thing in people who don't budget and use credit cards to pay for everything. Often, when the financial consequences are not immediate (like having to hand over those presidential flash cards (cash)), it's easy to run up bills we don't have impact us. That's why so many people end up in debt: no immediate financial consequence for their choices.

If you asked a hundred people on the street how much their doctor charges for a routine visit, I'd be willing to bet that the overwhelming majority (80% or so) would answer with either 'I don't know' of the price of their copay.

As for the general rejection of government control of anything (which is a lesson we learned because of the Cold War), it's because the government has no motive to make do with less and make the numbers work. And for all the problems (yes, the ones you list) we have with health insurance (which could be fixed by injecting real competition and sensible damned regulations (like protecting people that make good-faith mistakes from rescission)), it's a system that will not, of its own accord, collapse under its own weight.

As for Mediscare, while it has done right by many people, it's also a system in failure. When it does fail, there will be a scramble to either fix or replace it, and many people will have to find another way during the mess. But when the government is the only game in town, failure means there is no other way.

Satyavati devi dasi said...

One thing I've been thinking about, and that I think has been overlooked, is the provider. To educate a doctor to a reasonably competent level takes eleven years: four of premed, four of med, and three of residency. Tack on another couple of years if you're surgical or specializing.

This translates into coming out of school with the equivalent of my mortgage in debt. Faced with entry-level salaries, massive malpractice insurance premiums, and crushing school debt, it's no wonder that doctors are moving towards the 'more lucrative' specialty areas.

This leads us to a shortage of general practicioners. Plenty of areas in this country are already underrepresented with doctors (because big cities are where the big money is at-getting paid in cordwood and chickens won't help your school loan) and the system perpetuates itself.

To help the problem you have to go all the way back to education. There are already programs in this country where you can relieve some of your debt by practicing in underserved areas (where I live, despite being less than 50 miles from some of the world's top hospitals, is such a place). But if we could work out ways to eliminate most of that debt, and make it easier for doctors to survive in general-practice areas, it would take some of the lure of specialty work away, and fill the gaping hole that gets worse all the time.

We hear (I hear, anyway) all the time about the nurse shortage. I dimly recall hearing once about a physician assistant who paid off her school loans through a program where she worked on an Indian reservation for a couple of years. That's great. I haven't heard about that for nurses, though.

Years ago, when I was in highschool, the local vocational school had a program where you could go half a day for two years and when you graduated you were ready to sit for LPN boards. Now, this is a great idea. First of all, your education was free. Second, you're 17 (or 18) and kicking off a solid career. Third, you're sending someone into a desperately needed area of the workforce. There's no real downside to this I can see.

I don't know if programs like this are still in place, but if they're not, they should be. With vocational highschools prepping LPNS and community colleges bringing in LPN-RN bridge programs, you could get a huge number of new nurses out and working every year.

The system is bad and it needs to be changed and you already know how I feel about that, so I'm not even going there. This is strictly about the educational part of it. I think it needs to be looked at. We can't change it overnight, but there has to be a way. For the 09-10 year, Duke will cost you $53,390. I'm assuming that's for two semesters. I hope it's for two semesters. That's over $200K at the end of your premed, and then you've got med school to think about. It's a big deal. I think it gets overlooked in all of this.

Patrick M said...

Schooling cost is part of the problem (and hang on, it's agreement time). That's what makes it necessary for doctors to make much more than they do in France (getting back to the post): they have to pay loans off.

One of the points I have always focused on is use of nurses and even basically trained medical staff to handle the routine items. There are many things that are common that could be diagnosed by a nurse, and some common things that a lay medical education could easily spot and sort (and direct it up the chain to the nurses, then doctors).

Some of the stories you've told me in your work indicate that you often know what needs done and what will happen before the doctor even gets there to pronounce it so. And my experience with both a midwife and a nurse practitioner at the doctor's office convinces me that this is one step that will cover more people for less.

As for the costs, it comes back to looking at the smaller schools, the high school vocational stuff, or maybe even getting back to the old practice of apprenticeship. One thing I learned is that school does many things, but it doesn't prep you for the real world.

And perhaps unspecialization (which is what I wasted my 4 years of business college on) is the key to making the system affordable again.

Satyavati devi dasi said...

Unspecialization is kind of a scary word. I don't want a GP doing neurosurgery.

On the other hand, maybe we could ponder a system in which specializations have quotas. Of course this is going to probably ire your wide libertarian streak, but it is entirely possible to be oversaturated in one area and bare bones in another. Exactly how many pediatric-mixed-melanoma-and-congenital-immune-compromise specialists do we need? (I made that specialty up, just in case someone thinks it's for real.)

When you open a facility, at least here, you have to get a CON, which is a certificate of need. It has to do with the law and medicaid and all that, but basically it says that you have to prove that a need exists for whatever particular type of facility you want to establish.

If you want to be that mixed melanoma et al specialist, maybe you should be required to practice in a certain area that doesn't have one, and if there's already enough there, then you can either go into something else or go somewhere else. I don't know. That sounds awfully bad, but what's the point of having 200 people who specialize in one thing and no one who you can see for a cold?

There's problems with that whole idea, I can see it now. Doctoring is a glamourous business (until you get into it, I think) and shows on tv like Nip/Tuck (which I have never seen except for commercials) where you're surrounded by gorgeous women who want to be more gorgeous probably factor into a few kids' decisions to become doctors. There's a prestige factor too, that comes along with a title. Isn't it funny that everyone calls doctors Doctor, but it's rare you'll hear a nurse called Nurse?

Anyway. As far as the rest of what you said: personally, I have no desire to go back to school, do any kind of advanced-practice thing, or be diagnosing anyone. I'm comfy where I am. I do know that lots of girls are heading right for the NP straight out of school (mistake imho, but debatable). I think NPs have a place, but I also recognize that things are changing fast enough for me to be old-school and old-fashioned philosophically. So I might not be the best person to talk about the role of the NP, or the PA for that matter.

Satyavati devi dasi said...

And this morning I have another thought: there's been a lot of talk from your conservative flank about doctors and nurses providing free medical care et al.

This is a nice idea, except that it completely disregards the fact that our medical and nursing resources are stretched far too thinly to begin with. When you have nurses walking out of the field altogether because of burnout due to ridiculous ratios, crazy scheduling and mandatory overtime (not in California, though), and not enough GPs to manage as it is, to think that you can somehow supplement the gaping chasm of uninsured with people donating their time is naive at best and ignorant at worst.

These problems will also continue to exist when everyone has insurance. The inadequate resources we have will need to go even further than they do now. This is not (as I have heard it put forth) a good reason to not insure everyone. But it is reasonable to assume that when someone has been working their ass to a nub, they are not necessarily going to want to spend their day off working.

There's nothing essentially wrong with volunteer hours to try to pay off loans and do some emergency work in crisis areas. It is, however, not an answer to the problem of uninsurance.

Patrick M said...

Saty: A couple points to clarify.

First of all, where people are being worked to a nub, I'm certain there will be damned few people who will volunteer for more.

I think my ideas that I covered about finding ways to take some pressure off doctors (and even, above, nurses) is the necessary step to eliminating the overtimes and burnout.

As for the volunteer time, it only works if people see it as part of their calling, work for God, etc.

And certainly, that's not the total answer. There are a myriad number of things that have to be fixed. The entire delivery chain has to be revamped or you will get further chaos, and under a government system, you get rationing (as there's not enough money or doctors).

Satyavati devi dasi said...


Let's make something perfectly clear.

There's rationing now.

It's not something that is nonexistent and won't happen unless we put a government system in place.

Care is rationed daily, constantly, all the time, every day no matter where you are in this country.

It's rationed according to the whims of your insurance carrier, and it doesn't matter whether you've paid your premiums or not.

Let's just get that one straight right now.

Patrick M said...

There's rationing now.

Wrong-o. Rationing only occurs when you are given a certain amount and not allowed to exceed that amount.

Not to come to the defense of the insurance companies who deserve a spanking here, but if they say no, there are still options, even if they suck. I have a related post in mind that will address this.

Satyavati devi dasi said...

So when the insurance company cuts you off because you've gotten really sick and they've decided you're no longer profitable, that's not rationing?

Don't be so fucking nitpicky semantic.