Recalling an old post: Le Havre and not paying for health care -- in France

Sometimes I think about old posts, and how sad it is that things have not changed in the years since I wrote them. But, as with this one, from Jan 12, 2012, I enjoyed writing it, and highly recommend the film that inspired it, Le Havre.

 One thing to NOT worry about: paying for health care -- in France

In Europe, health care does not bankrupt people. And universal coverage means they get the care they need.

A recent note from a friend of a friend:

‘Here we are in the Pyrenees foothills outside Perpignan [France]. An hour away from the closest ER. X was in the hospital with afib [atrial fibrillation, a heart rhythm disturbance] before we left for France in July and I’m worried about being so isolated. So in Sept he seemed disoriented for a few moments and I was worried so called the French version of 911. I just told them what was going on and they connected me directly with a doctor. They sent an ambulance. The EMTs thought he was OK after checking. But just in case, they SENT A HELICOPTER WITH A DOCTOR from Perpignan. Who also thought he was probably OK. But to be safe they took him by helicopter to Perpignan, arriving in nine minutes. They kept him overnight and let him go the next morning. He’s fine. I had to call them three weeks later to ask for a bill. They emailed it to me. It was itemized: ER, helicopter, two cardiologists, several imaging tests, overnight stay. Total price (for the uninsured): 249 euros.’

Wow! How much is a Euro? Must be like 10, or 100, times as much as a dollar, right? Um, no. Actually, with its recent fall the Euro is just about exactly $1. So $250 for all that? Unbelievable! In fact, if the Euro was worth $100, it would be $25,000, which would still be a lot less than the cost would have been in the US. If you could get that kind of care!

Indeed, that was the situation for this same family earlier…

‘Five years ago X had another chronic problem which has mercifully since been totally fixed. We came here, it started up, and we ended up with five ER admissions, six weeks in private rooms, 3 specialists, transfusions, intensive care, many tests, IV antibiotics etc etc etc. Total bill: about 20,000 euros over 6 weeks. Then back to [hometown in US], one night at [university hospital]: same price.’

What is going on here? It really is unbelievable! Except what is unbelievable, to people in France, or most of Europe, or most countries in the wealthier part of the world, is that we would find their out-of-pocket cost of care surprising. Everyone thinks, to some degree, that what they know, what their world consists of, is pretty much normative, that it is the same for kind of the same people everywhere. In fact, even when they intellectually know that it is not true, it is still one’s instinctive reaction, to think that what is normal for you is normal. Luckily for the French, what is normal for us in the US, in regard to the cost of healthcare, is not normal for them. And, of course, unluckily for us. And this is not a recent change.  It wasn’t even new back on January 21, 2012, almost 11 years ago, when I wrote ‘One thing to NOT worry about: paying for health care -- in France. Or for decades before that. In that piece, I wrote about going to see the film Le Havre and noted that in it a really poor person spends weeks in the hospital and the one thing no one is worried about is the cost. This could never be true in the US.

Doesn’t this upset you? Don’t you think something is wrong here? What is going on????

Sorry.  Of course it does. But, you know, it must be costing someone a lot of money, even in France, or wherever. All that health care, all those hospitalizations, all those tests, do not come cheap.

No, they don’t. But they don’t have to be so expensive. There is incredible markup on the bills and amount paid in the US. Not that anyone actually knows what the price is, or that there is any consistency to it.  US hospitals do have a Master Price List (like “one gall bladder surgery, $X) but it rarely is what is either billed or paid. These hospitals have deals cut with large insurers on how much they will be charged, and pay, on behalf of their customers. Medicare, the government insurance system for the aged and disabled, sets its own rates as to what it will pay (and the private insurance rates are usually expressed in “multiples of Medicare”). Really the only people who might be charged the “list price” are those who are uninsured and poor, those least likely to be able to pay it – although very few of us could pay those amounts! The couple who wrote about their experience in France is obviously well enough off to have spent that time in France, and to have paid their bill, but just being reasonably well off is far from sufficient to be able to pay hospital bills out of pocket.

Let us be entirely clear and simple: The reason US health care costs so much is profit. It is that everyone, everywhere along the line, is taking a cut. The insurance companies, right from the start, huge profits (and salaries to their executives). Hospital systems, huge markups (and salaries to their executives). Pharmaceutical companies, huge markups (and salaries to their executives). Doctors also, especially in some specialties. I could give lots of examples of those specialties with the highest income/work ratios. It is not because we use “too much health care” – indeed, it is really unlikely that any of us (unless a billionaire or a head of state) could have gotten the care that X did in France, and they did that just “routinely”, because it was what they thought was medically the right thing to do.

That, of course, is the other part of this story. It is not just that the charges and costs to the individual were so much less than what they would have been in the US. As a physician friend pointed out “The dollars and cents issue is important. But freeing the medical community to just do the right thing is immeasurable.” Think about that. At each stage, from the person’s wife calling French 911, to the EMTs who came, to the doctors who decided to airlift him to the city, to those who cared for him in the hospital, the decisions that they made were medical, what, in their judgement, was the best for the health of the person/patient. At no point did the cost of the care enter into their decision. Well, I take that back. It may have. But what did not enter the decision was “what kind of coverage does this particular person have? Does it pay enough? Does it cover what we want to do? Have they met their deductible? Can they afford the copay?” This is what you would want for your own health care, and it is absolutely what doctors and other health professionals want to be able to do. Once there was a joke (what today would be a meme) that before doing a procedure the doctor would do a “wallet biopsy”. Today, it is more often the hospital, and it is more likely an “insurance biopsy”. This is crazy.  It is crazy. It is unacceptable. And more important, it is unnecessary.

And the cost of health care per capita is much LESS in France, just as the quality of care is higher (as I cited from the Commonwealth Foundation in my last blog post, Premiums are up, people are dying and insurance companies are making out like the bandits they are, October 25, 2022). Indeed, it is less than half the per capita cost in the US. And in France, that includes everyone; no one is without coverage.

Of course, not foreigners, like those visitors from the US, who had to pay their whole bill themselves with no insurance.  All $250 of it.

How the left is losing the COVID “war”

Guest post by Edgar Blaustein.  Originally posted at Medium.com

Can the left already be losing the political war regarding the COVID pandemic?

A look at the political impact of the current coronavirus crisis in the United States, the United Kingdom and France, and what it might portend for the left.

Hail to the chief! Pandemic as legitimization

Donald Trump’s, Boris Johnson’s and Emmanuel Macron’s rise to power share key similarities: lack of legitimacy, and, for Trump and Johnson, appeal to nationalist sentiments (MAGA, Brexit). Trump through lies, luck, and electoral math won the Presidency with less than a majority of voters. Johnson won through lies on Brexit (no hard borders, more money for health services). Macron won with less than a quarter of votes in the first electoral round. Nevertheless, the winner takes all systems in all three countries gave the victor complete control of the legislative and executive branches of their respective governments. Though lacking legitimacy, all three wanted to think of themselves, as great war leaders such as Churchill, Roosevelt or De Gaulle.

Unlike the World War II leaders, our modern day chiefs have had the leisure over the last several years to choose their wars. Trump’s initial attempts failed, as he was outmanoeuvred by Xi Jinping and Kim Jong-un. Trump and Pompeo sounded the drums of war with Iran, but Iran, notably through attacks on oil tankers and a Saudi refinery, stopped US escalation.

Johnson’s chosen enemy was the European Union, framed as a faceless foreign oppressor, trying to grind down the plucky English. But “getting Brexit done” ran up against barriers: no hard frontier” between the Ireland and Northern Ireland, and the impossibility of assuring economically vital free trade with Europe without membership in the European Union.

Macron’s struggle was against “recalcitrant” sectors that opposed his vision of the “modernisation” of France, clinging to “outdated” notions such as progressive taxation, unions, worker’s rights, public services, or a public retirement system. Macron had won most battles, but the ceaseless conflict — with the gilets jaunes, trade unions, students — had taken its toll, and at the end of 2019, Macron’s government was visibly suffering from wear and tear.

At the end of 2019, all three leaders were in difficulty. And then came the coronavirus.

The birth of the war against a virus.

German President Frank-Walter Steinmeier said “This pandemic is not a war. It does not pit nations against nations, or soldiers against soldiers. Rather, it is a test of our humanity.”

And yet, the three leaders wound up framing their reaction to a health emergency as a war. But the path that led them to the war paradigm was far from direct. Indeed, in a first phase, all three initially downplayed the risk of the pandemic. In a second phase, they for a short while followed the “herd immunity” strategy, letting the infection run its course. And then in a third phase, all declared war on the coronavirus.

The three leaders hesitated, contradicted themselves, changed discourse, lied about the lack of personnel protective equipment, were contradictory on the subject of tests, all in frantic efforts to avoid assuming responsibility for massive unemployment and tens of thousands of unnecessary deaths. Trump’s “I take no responsibility” will certainly go down in history.

The three tried to frame their failures as responsible action to find balance between the health and economic impacts. As the double health and economic crisis deepened, they pivoted to “communicating”, a difficult task, since several countries — South Korea, Taiwan, New Zealand, Germany, Viet Nam, the Kerala state in India, among others — have demonstrated that rapid effective action on health, combined with a strong safety net for workers, leads to optimal economic as well as health results.

There appears to be no simple left/right divide that explains which countries have been most successful in meeting the crisis. Some rightist or extreme right governments — Poland, Germany, Austria, Australia or Japan — have done better in dealing with COVID, than the Social Democratic governments of Spain or Sweden. It does seem that women leaders, whatever their politics — New Zealand, Taiwan, Germany, Iceland, Finland — do better than men.

The countries that did not act rapidly have had to impose lockdowns, a blunt medieval pandemic control instrument that dates back to the time when humanity knew very little about the science of disease. Lockdowns are in no way progressive, although progressives must respect them when there is no better alternative, as in the case of our 3 countries.

The combined health and economic crisis in these three countries represents a severe threat to the legitimacy of their leaders. The depth of the crisis and the loss of legitimacy of the governments has led many leftists to imagine that we are on the brink of radical change, even the end of capitalism. The remainder of this article will argue that this is not the case, and that whatever our long term goals are, in the short term we should focus on more immediate achievable victories.

COVID is worse for the left than the subprime crash.

The 2007–2010 financial crisis was triggered by the collapse of Bear Stearns and Lehman Brothers, in the very heart of the capitalist financial system. The “shadow bankers”, who engineered the 1999 repeal of the Glass-Steagall Act walked away with hundreds of billions in profits made during the decade of the expanding bubble, while the general public paid for the crisis when the bubble burst. At the time of the subprime crisis, many people (author included) thought that the bankruptcy of the capitalist system had been made evident to the majority, and that the way was open for radical change. The crisis gave rise to the occupy movements, their European variants such as “indignados”, and in part to the Arab Spring and “Nuit debout”.

The actual results over the last decade were the opposite of radical progressive change. Economic inequality increased, the hold of bankers on public policy expanded, the influence of the right wing press increased. Authoritarian regimes have come to power over half the globe. Democracy, trade unions, free press … all declined. As Naomi Klein has argued (“The Shock Doctrine: The Rise of Disaster Capitalism”), capitalists are generally better equipped than progressive forces to take advantage of a major shock. Furthermore, the specific nature of the COVID crisis makes a radical change even less likely than was the case in 2008.

• Capitalism did not cause COVID. Indeed, the modern capitalist system has contributed to the coronavirus pandemic, through globalisation-driven increases in travel, through accelerated exploitation of natural resources that increase interactions between wild animal populations and human activity, and through the neo-liberal sabotage of public health systems. Nevertheless, it is false, and harmful for progressive forces, to argue that capitalism caused COVID. Viruses, animal to human transmission, and long range trade all existed long before the emergence of capitalism.
• COVID weakens intergenerational solidarity. The lockdowns strike most heavily on the finances of the youngest, whose professional and economic situation is often fragile. In contrast, older people, a majority of whom have a stable retirement income, suffer most from the health risk of the double crisis. This divide in material interests, coupled with the lack of close links between generations, has led to a political divide.
• Weaken class solidarity. COVID divides workers by race, by class, and by type of work. The most obvious cleavage is between white collar workers who can telecommute, and essential blue collar workers who are exposed to sickness. Furthermore, since many of the essential workers are from minorities, this distinction is also of a racial nature: Black people are 4 times more likely to die than the general population in the UK, and 3 times more likely in the US.
• Increase oppression of women. In normal times, many two income families “outsource” the principal domestic tasks: childcare, cooking, cleaning. This has ended under lockdown. Furthermore, with schools closed, home schooling is a new domestic task. It is no surprise that women have assumed a major share of this increased workload.
• Physical distancing degrades the tissue of society. Staying 1 or 2 meters away from other people is a physical measure to prevent the spread of the corona virus. Breaking down social links is an unfortunate, and perhaps partially unavoidable, consequence. This frazzling of the tissue of society is harmful for progressives, since our main tools for collective action — demonstrations, public meetings, civil disobedience, strikes — are difficult or impossible for the moment. The rise of telecommuting will most likely make it even harder for unions to penetrate into tech related industries. Naomi Klein, in “How big tech plans to profit from the pandemic”, shows how the “tech bros” plans to make use of the crisis.
• Justify the permanent surveillance State. “Test, trace, isolate”, while essential to fight COVID, nevertheless involve public intervention into the private lives of citizens. Successful programs in China, South Korea, Taiwan and Hong Kong all involved massive privacy intrusions. China, in particular, has woven the COVID tools into already existing, widespread programmes of surveillance of citizens lives. We can expect that these surveillance tools and powers will be used against progressives.
• War on truth. Rightists have made a scale change in their war on truth. The chloroquine controversy, built on the basis of nothing, is just one example. Rightists no longer attempt to counter the truth, they simply bury it under a constantly growing pile of rumours, factoids and lies. Hannah Arendt, in “Lying in Politics: Reflections on The Pentagon Papers”, explains that the fog of lies aims to make both thinking and action impossible.
• Democracy, pollution, climate. It is clear that different strands of progressive movements will have lost ground and lost momentum during the pandemic. For instance, President Donald Trump signed an executive order to ease up on businesses that make so called “good-faith” attempts to follow regulations during the coronavirus pandemic. This text will not detail the many other cases of using the crisis to weaken democracy, and to sabotage regulations on the environment.

It thus appears that the specific nature of the COVID crisis will leave the left in a weaker position than was the case after the subprime crisis.

We are not in a pre-revolutionary period

Six months ago, the UK, France and the United States were led by men who, even if they were stumbling, were strongly supported by at least a substantial minority that was enthused by their nationalistic, racist, xenophobic fear mongering. Certainly — as shown by Bernie Sanders, Jeremy Corbyn or Jean-Luc Mélanchon — there were also substantial minorities of mostly young people that give enthusiastic support to reformist candidates critical of capitalism. Nevertheless, the three radical reformists have all lost elections to more conservative politicians: Sanders lost to Biden, Corbyn to Johnson and then Keir Starmer, and Mélanchon to Macron and Le Pen. From these results, we conclude that the support for substantial reforms stems from perhaps 20% of the population, far from the overwhelming large majority that could be the basis for a mass movement for radical, post capitalist change.

The COVID crisis paradoxically weakened the political support for the three Presidents, while at the same time — for reasons outlined above — weakening the tactical capacity for action by the anti-capitalist left. In this context, the killing of George Floyd and the BLM and related movements swept across all three countries. From the point of view of the author, the BLM movements are radical in character, but reformist in their demands, mostly seeking limited reforms of a democratic nature: the right for people of color to live without fear of being harassed, beaten or killed by police. The achievements of the ’60s civil rights movement shows that this and related BLM demands are hugely important, and nevertheless achievable within the current political and economic system.

Since the end of decolonisation and the wars in South East Asia almost half a century ago, the left, with the exception of victories on women’s and LGBTQ rights, has lost more struggles than it has won. Today, over half of our planet’s inhabitants live in countries controlled by different types of authoritarian, xenophobic and racist regimes.

The left desperately needs short term victories to reverse the drift towards authoritarianism. While the current situation is not in general favourable for progressives, the specific nature of the COVID crisis in the three countries could lead to victories on specific objectives, such as the following.

• Rebuild public health systems, and public hospitals.
• Universal health care. Millions of Americans lost their health care when they lost their jobs. The spread of the virus in poor communities shows that health care must include undocumented workers and families.
• Vastly increase international cooperation on preventive health issues. We cannot avoid a future pandemic unless all countries, even the poorest, have the capacity to rapidly identify and isolate new diseases. We need a strengthened WHO. Even the most closed minded of capitalists can understand that spending a few tens of billions per year to build up world health systems would cost much less than the next pandemic.
• Increase protection of workers in times of unemployment, both through financial support, and effective retraining to allow workers to adjust to inevitable economic change. Again, a portion of capitalists would support such action.

The BLM movements show support exists for another category of actions, focusing on policing, and more broadly on systemic racism. Two types of measures should be within our reach:

• Measures to limit police violence in poor communities, such as always-on body cams, new rules for use of firearms, end of choke holds, effective surveillance of deaths of people in police custody, some kind of control on abusive stop and frisk, or transferring some police functions to unarmed civilians. These measures broadly correspond to the slogan “defund police”.
• Measures to reduce discrimination against minorities in employment and in the media. The actions of several large enterprises (for instance in the Facebook boycott) show that large parts of the capitalist class will support some measures.

Three other measures might be within reach.

• a guaranteed of a job or of a basic income. This would be cheaper than the current hodgepodge of measures, and would be a more effective countercyclical Keynesian economic shock absorber. Unfortunately, opposition might come as much from some workers as from capitalists.
• deepening of democracy, or at the least limiting of corruption.
• perhaps a more progressive tax system. Possibly a one time special COVID wealth tax on multi-billionaires, to repay the public borrowing during COVID. Spain may create such a a wealth tax. Perhaps some kind of reparations for slavery.

We should use the opportunity of the weakness of our rulers to fight for significant and achievable short term goals. We need victories to strengthen progressive movements, to improve our capacity to win future battles. We must at the same time keep in mind our long term goals, and use the experience we gain in short term struggles to develop common ideas on our vision for the future, our strategies, our alliances, our tools and modes of action.

This text benefited from the generous help of Robert van Buskirk and Jérôme Santolini, who kindly contributed, even though they disagree with major portions of the text.

"Single Payer", "Medicare for All": Good ideas and about time!

The call for a universal health care system in the US is probably greater than it ever has been. While, of course, the Republicans, whose only firm position is completely kowtowing to billionaires and major corporations, are opposed to it, many Democrats have signed on to the “Improved and Expanded Medicare for All” bill in Congress (120 at last count). Democrats running across the country have been calling for “single payer” as well as “Medicare for All”, from outspoken Democratic socialists like Alexandria Ocasio-Cortez in NY (and of course Bernie Sanders) to moderate Democrats running in states and districts that Trump won. They correctly see this as an issue that cuts across traditional liberal-conservative lines, and even racial lines, and may be their path to victory.

Many Republicans (although not the Republican congressional leadership) are reading the same tea leaves, and are hedging, trying to say that they favor the things that people like about the ACA (most important, the protection against insurers denying coverage for pre-existing conditions). Of course this often requires major dissembling for those who, like our Arizona GOP candidate for Senate Martha McSally, voted to gut the ACA, and even Texas senator Ted Cruz who authored the “Cruz Amendment” that would strip virtually all protections for people under ACA. President Trump, never one for nuance, has no difficulty having it both ways: he calls for the repeal of ACA while insisting that his health care plan will protect people’s ability to have health insurance, pre-existing conditions or not (it won’t).

It is in this context that the recent Sunday NY Times’ Magazine article by Elisabeth Rosenthal and Shefali Luthra, ‘“Don’t get too excited” about Medicare for All’ becomes important. For starters, “Don’t get too excited” is not necessarily the opinion of the authors but a quotation from Rep. Jim Cooper (D-TN). Rep. Cooper was responding to the surprise of one of his Nashville constituents, Dr. Carol Paris, President of the leading physician advocacy group for single payer, Physicians for a National Health Program (PNHP), that he had signed onto the Medicare for All bill. Nonetheless, the article does raise many cautions about the movement to single payer or Medicare for All, mainly about different interpretations of the meanings of this by different advocates, and incomplete and sometimes inaccurate understanding of them by regular people. The most important thing about it, however, is that it had to be written at all because there is such a movement; long-time activists, including PNHP physicians, remember that it was not too long ago that such an idea was poo-pooed, dismissed. Not now.

Clearly, the quantum step forward was the 2016 presidential campaign of Bernie Sanders. The establishment pundits of both parties were shocked at how popular and successful this old Jewish socialist from Vermont (ok, originally Brooklyn) was across the country. He didn’t win the Democratic nomination, true, but he might have won the general election against Trump. Certainly, his straight talk and the fact that he directly addressed the felt needs of regular people was the main reason for his popularity, and people’s fears about their health risks and costs were central to this (see A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care, October 16, 2018). Bernie had advocated for single payer for decades, as had great leaders before him including the late Representative Ron Dellums of California (see Ron Dellums: Loss of a great leader and a job for the rest of us, July 31, 2018), but the visibility of his presidential campaign skyrocketed the visibility of single payer.

Rosenthal and Luthra utilize a good bit of ink describing what single payer is --the government is the only payer for health care, rather than multiple private insurers; Canada is the best example of this, and Britain has a government-owned national health service. They also note that Medicare for All means exactly that, that everyone, not just those over 65 and the blind and disabled, would be in the Medicare program. Of course, since Medicare is a single payer program, it would be single payer. They describe the misconceptions people have (“would I be able to keep my present plan?”), and also talk about other countries, such as France and Germany, that have universal health care without a single payer but with a heavily-regulated marketplace. They observe that partialist solutions do not generate the enthusiasm of single payer, but that the latter would be the hardest and thus (perhaps) most difficult to institute. Among the concerns they note are the displacement of insurance company employees and the decrease in doctors’ income.

But these are the most important points.

1.       Our health care system is not working. Our life expectancy is much lower than other developed countries, about 43^rd, and a recent article in Smithsonian Magazine covers work that projects that it will drop another 21 places by 2040, to 64! Other measures of access to care and quality of care are comparably poor. Yes, there are heroic and wonderful things that medical care can do for people, but if these are not accessible to everyone, and if the cost of them precludes spending on even basic care for everyone, it is not working.
2.   Our health care system is incredibly costly. By far, we spend more, overall, as % of GDP, and per capita, than any country in the world, as illustrated by the graph from the Kaiser Family Foundation. It is more than twice as much as most of the developed countries, all of which have far better health status.
3. Profit is the problem. Specifically, corporate profit made from providing health care services (or, in the case of insurance companies, not providing health care). This is how we manage to do both #1 and #2 – because the functional goal of the US health system is not to increase the population’s health but to make as much money as possible for insurers, hospitals, drug companies, and providers.

These are the core issues that need to be addressed, and what sets the US apart from all other developed countries. Yes, Canada has a single payer system such as we might have with Medicare for All (and they even call it Medicare). Britain has a National Health Service, with most hospital and health care facilities owned by, and some doctors employed by, the government. Britain, however, allows private insurance for those who can afford it, Canada does not. France and Germany and Switzerland have multiple insurers, but they are not unfettered to maximize profit by denying care. In Switzerland, for example, insurers have to be non-profit, have to offer the same benefits, and have to charge the same amount. They compete on quality of service! Can you imagine that here?

So, while Rosenthal and Luthra repeat the idea that single payer, although the most enthusiasm-generating, would involve the biggest change, it is also, in another sense, the least complicated. Trying to get to a system like that that evolved in these other countries over decades will be more complicated to understand and to implement. Many of the suggestions for incrementalism (“Medicare for More”, “public option”) will not solve the problems we have because they do not include everybody, and because they do not eliminate the incentive for making money on the back of denying care that is the core flaw in our current situation.

“Medicare for All” and “single payer” are popular among people because their core meaning is understandable, and they would address the needs that they have.

• ·        Everybody in, nobody out!
• ·        No profiteering!

Simple message. Needed solution.

Free speech, religious belief, and facts: how does it affect health?

The massacre at the French magazine Charlie Hebdo was shocking and horrible, as are the massacres and atrocities that occur regularly with less immediacy to those in the West, such as those committed by Boko Haram in Nigeria. The most positive result was the massive outpouring of support for free speech, for being able to say and print what you want even if it offends people. And, I would add, particularly if it offends the powerful, which Charlie Hebdo also did. More than a million in the streets of Paris saying “Je suis Charlie” (“I am Charlie”), with more than 40 heads of state in attendance, even if they didn’t actually lead the march, but were photographed together on a protected side street. And even if many of them sponsor severe repression of free speech in their home countries. 

The inclusion of Israeli Prime Minister Benjamin Netanyahu was particularly problematic given the violently repressive policies of his government, but given that the companion attack was on a kosher supermarket where four Jews were killed, the symbolism was important even if a lightning rod for (largely just) criticism of Israeli government policy. Less appreciated was the message from Netanyahu that French Jews should all come to Israel, and more appreciated were the sentiments of French Prime Minister Manuel Valls that ‘France Without Jews Is Not France’, and the demonstrators, most of whom were not, who carried signs that said “Je suis juif” (“I am Jewish”).

But the necessary condemnation of terror, and moves to avert it, along with the necessary condemnation of anti-Semitism and the conflation of Jews with the actions of the government of Israel (or the conflation of Islam with the actions of Islamic terrorists) does not solve the problem of communication, that people see “truth” so differently. I don’t know that I can offer much more insight into the conflict of seeing truth through the lens of religious doctrine (and of course some people and groups’ interpretation of religious doctrine) and a “liberal” concept of the value of free speech. I was interested in the perspective of Maajid Nawaz, a British Muslim who became a radical Islamist at 16, served 4 years in an Egyptian jail where his readings changed his perspective and later founded Quilliam, an anti-jihadist think tank in London, expressed on NPR’s Fresh Air. Asked by host Terry Gross how he saw himself as the same person, given his loss of relationships including family and friends since his “conversion”, Nawaz spoke about commitment to justice. He said it was the blatantly unjust treatment of Muslims that motivated him to fight as an Islamist, and the same commitment to justice that makes him oppose terrorism. Ideologically, I think that this is a good start.

 Most countries, including France and the US, have a mixed relationship with free speech. In the US (which I know much better), many people not only support free speech for positions that they agree with but also positions that they can tolerate listening to. Of course, however, true support for free speech means support for speech you abhor, hate, despise, think dangerous. Not, of course, the same as action (“your free speech stops just short of my nose”), but certainly includes free assembly and demonstrations to express views. If one’s religious views include opposing anyone’s right to criticize your religion (or, even more, as illustrated by the Inquisition or ISIL’s massacres of Yazidis, not adopt your religion), you are clearly endorsing a society antithetical to free speech. And, of course, with the grossly immoral series of US Supreme Court decisions that money is speech and that corporations are people who can exercise that “speech”, the entire concept of free speech in our country is perverted.

Closer to home, and closer to the usual themes of this blog, health and social justice, we see again how beliefs not only threaten free speech but threaten our ability to act as an honorable and just society because groups of people see things so differently. The reasons given are many: our social isolation from groups of people unlike us (residential segregation by race and class and age and educational level), our ability to receive “customized” news, where what we watch on TV or find on the Internet is that which agrees with what we already believe. When people hold views based on their faith, it may be difficult or even unreasonable to expect to change it; this is what “faith” is. However, when people hold views that are not religious and are demonstrably wrong in the face of the facts, and those beliefs are held as firmly as those that are religious, and those beliefs threaten the core well-being of other parts of our society, we would hope that they could change.

I have often written about the Social Determinants of Health. These are the conditions of people’s lives that make them more vulnerable to illness, less likely to be able to prevent it through both health screening and living in places and circumstances in which prevention is possible. For example, not near areas of high pollution, not in poor quality cold housing, not in no housing. To have shelter, and decent food, and the opportunity for education for themselves and their children. All the things that characterize their lives and come before their access, or lack of access, to the health system comes into play. If we are to improve the health of the American people, we must not only provide equitable access to health care geographically, financially, and socially (with language access and caring and actual interest in people’s health) but also address those social determinants that disadvantage so many in the pursuit of their health.

 

And then I read the results of a survey by the Pew Research Center that says a majority of well-to-do Americans think that poor people “have it easy”. Widely reported, including by the Washington Post which leads with “There is little empathy at the top”, and CNN, which reports “54% of those with the greatest financial security believe that ‘poor people today have it easy because they can get government benefits without doing anything in return’…Only 36% of the wealthiest say ‘poor people have hard lives because government benefits don't go far enough to help them live decently.’" I want to say this is unbelievable, but I have to believe it is true that they think this. I am, nonetheless, aghast that they could think this. What world do they live in? Is it really true that their only contact with poor people is on TV news, Fox News at that? Have it easy?

Would they want to test that? Live like poor people for a while? Even knowing that – unlike real poor people – they could return to their comfort in a month or a week, would they be able to tolerate it? Not being able to pay their bills, not have heat, not have decent or sufficient food, not be able to afford the doctor, not be able to take off work without losing pay to go to one even if they had health insurance? I think – I know – that if they did they would feel differently about it being easy to be poor. But while there is great value to “walking a mile in someone else’s shoes”, there is a way to know what is going on without even doing that. It is called opening your eyes, looking at the facts.

Even when they are uncomfortable, even when they challenge your beliefs, or more importantly your sense of self-entitled comfort. To not do so is part of no one’s religion. This is the responsibility of free people. 

The high cost of US health care: it's not the colonoscopies, it's the profit

On June 2, 2013, the Sunday edition of the New York Times ran a major investigative article by Elizabeth Rosenthal called “The $2.7 Trillion medical bill”, with the subtitle “Colonoscopies explain why the US leads the world in health expenditures”. It is a damning article about the US health care system, and the fact – fact – that our costs are much higher than those in other countries but our outcomes are often worse, and large portions of our population are not even covered.

Of course, it is not all colonoscopies. Yes, the average cost for a colonoscopy in the US is $1,155 compared to $655 in Switzerland (for example). And many cost much more; in the first paragraphs of the article we hear about charges of $6,385, $7,563.56, $9,142.84 and $19,438 -- “…which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.” ! But the graphic at the top of the article compares US prices for other common procedures with those of other first-world countries: Angiogram $914 US, $35 Canada; hip replacement $40,364 US, $7,731 Spain; MRI $1,121 US, $319 Netherlands; Lipitor (atorvastatin, a drug to treat high cholesterol) $124 US, $6 New Zealand.

But colonoscopies provide a good example for why we pay so much more for procedures – and it is not because they are of higher quality:

“Colonoscopies… are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs. Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.

The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.”

Welcome to the world of for-profit health care. Where the principle of “maximize profit” determines what health care institutions do. Where “what we do” (our “product”) is health care, but we prefer to do it on those with really good insurance. Where we adjust our charges to maximize the difference between what it costs us and what we are paid. Where the rules set by insurers or government with the aim of regulating costs are seen as challenges to be gamed for maximum profit. The movement of colonoscopies – and many other procedures – from doctors’ offices to “surgi-centers” is a great example. If performing colonoscopy in an office was unsafe, moving to a surgi-center might be a good idea, but there is little evidence that it was. Moreover, the increased price for performing a procedure in such a center far exceeds the increased cost of doing it there; the reason for the move is not patient safety, but taking advantage of a loophole to be able to charge more.

Rosenthal’s article is a long one; it extensively documents both the high cost of health care in the US and the reasons why it is so high, which are rarely related to quality. This is illustrated by an article published in the Times a few weeks earlier, “New Jersey hospital has highest billing rates in the nation”, by Julie Creswell, Barry Meier, and Jo Craven McGinty. “The most expensive hospital in America is not set amid the swaying palm trees of Beverly Hills or the luxury townhouses of New York’s Upper East Side,” they write, but Bayonne Medical Center, in Bayonne, NJ, where the average charges are 4.1 times the national average charge, not to mention what Medicare will pay. For some services it is much higher: “Bayonne Medical typically charged $99,689 for treating each case of chronic lung disease, 5.5 times as much as other hospitals and 17.5 times as much as Medicare paid in reimbursement. The hospital also charged on average of $120,040 to treat transient ischemia, a type of small stroke that has no lasting effect. That was 5.6 times the national average and 23.6 times what Medicare paid.”

How can they get away with this? Who will pay them so much? After all, if I can buy a Chevrolet for $25,000 at one dealer in town, why would I pay $75,000 for the same car somewhere else? Ah, but health care is different. For one thing, you might be sick when you have to find a hospital to care for you, and you might live in Bayonne! Of course, Medicare will only pay what Medicare pays, but if you have most types of commercial insurance (not to mention, of course, if you are uninsured), it is another story. To guard against excessively inflated charges, most insurers have contracts with providers (hospitals, doctors, etc.) that determine how much they will pay for a procedure or treatment of a disease. This saves the insurer money. In addition, in order to encourage you to go somewhere that they have negotiated these lower rates, “in-plan” hospitals, they pay a lower percent of the cost – and you pay more – if you go “out of plan”.

And it is precisely this effort to control costs that many for-profit hospitals (like Bayonne) have turned on its head to generate greater income. They have gone “out of plan” for all health plans. This means that when you show up in their ER, or are admitted, you have a higher co-pay, and co-insurance charge, and the insurer pays them more money. Which is why the insurer doesn’t want you to go there, and you might (once you knew this) not want to go there either. Except, of course, you’re sick, and you live in Bayonne, and it is the closest ER. Talk about gaming the system!

Spending & Coverage (2010)	France	U.S.
Total health spending per capita	$3,974	$8,233
Government health spending per capita	$3,061	$3,967
% uninsured	0%	15.7%
Health outcomes (2010)
Life expectancy at birth (2011)	81.3 yr.	78.7 yr.
Infant mortality per 1,000 births	3.6	6.1
Costs per episode (2012)
Doctor’s office visit	$30	$95
Hospital day	$853	$4,287
Angioplasty	$7,564	$28,182
Appendectomy	$4,463	$13,851
Childbirth delivery (normal)	$3,541	$9,775
Hip replacement	$10,927	$40,364
Heart bypass	$22,844	$73,420
Tests (2012)
Abdominal CT scan	$183	$630
Angiogram	$264	$914
MRI	$363	$1,121
Name-brand drugs (30-day prescription, 2012)
Cymbalta	$47	$176
Lipitor	$48	$124
Nexium	$30	$202
Sources: Organisation for Economic Co-operation and Development and International Federation of Health Plans.

I have implied that much of the reason for the high cost of health care in the US is the high cost of procedures. Frankly, that is true. It is why procedural specialists make so much more than primary care physicians. This is why decreasing the difference in income potential for proceduralists and primary care doctors would be good for everyone and save money: there would be more people doing primary care and less incentive to do unnecessary procedures. Consumers Report, in its July 2013 issue, has an article on the patient-centered medical home (PCMH) movement, which seeks to achieve the “triple aim” of higher quality, greater patient satisfaction, and lower cost. The article, “A doctor’s office that’s all about you”, also addresses the high cost of care in the US, comparing it specifically to France, which spends 11.6% of its GDP on health care and  “…is generally acknowledged as having one of the world’s best health care systems.” Needless to say, the comparison is not flattering to the US, which spends 17.6% of GDP on health care.

Richard Wender, MD, a leader in US family medicine, commenting on the “Colonoscopies” article, says “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation.” Lee Green, MD, an American who is now a family medicine leader in Canada, adds “Having practiced most of my career in the US, and now practicing in Canada, the contrast is quite evident. The US health care system is not designed to get you the care you need, it is designed to get you the care that someone can make a profit giving you. If you're poor and uninsured, that's none - no matter how much you need it. If you're well-insured, it's a lot - including quite a bit you don't need, and even some that is harmful.”

This is crazy. We know the problem, and we know the solutions. All we need is the will to implement them. Maybe this continued exposure will generate it. We can hope so.