Jane B.'s Blog

Why 'grandma' doesn't die...

2009-08-22T08:38:34Z

There are many ways to talk about the "unnecessary death rate" of a developed country. I linked to one article defining it in my previous blog post. One of the simplest ways to define it is to say it is the number of deaths that occurs due to lack of access to proper medical care.

For the first time in the US, it is not simply the unemployed or financially precarious who lack access to medical care: it also depends upon the fine print in your insurance policy. I believe this is why there are an alarming number of older people holding these pathetic signs about "grandma" dying because Obama's lying and the like. They utterly fail to see what is happening to younger generations in the US. Their plans were put into place in a period of relative prosperity when health insurance companies actually paid for healthcare with no lifetime limits and no strings attached.

This article, about a courageous doctor who has set up a chemotherapy unit in an abandoned warehouse facility in Nevada (for patients whose insurance fails to cover these costs) is a dramatic illustration of the phenomenon.

I know we are sick of hearing about death panels, but perhaps we should simply consider this term with a new target group in mind. It is not end of life decisions that are the crucial issue. People over sixty generally (though not all) have excellent healthcare plans. It is young to middle aged working adults who are now dying because they cannot get the medical care they need.

Getting Cancer in a 'Hell Hole' Socialist Country

2009-08-12T15:24:04Z

TPM has a fasicnating headline today about about mistaken assumptions: on the face of it, it's just an embarrassing blunder. The editor of Investor Business Weekly speculated that the eminent scientist Steven Hawking would have been eliminated by NHS death panels had he been, erh.. British.

As embarrassing as that is, not knowing Hawking's nationality is a mere detail. The real mistake, far more ominous for its ignorance, are the mistaken assumptions flourishing in the media about "hell hole socialist countries" and "death panels."

I live in such a country (France) though I am American and I should probably go ahead and admit that I am also a citizen of the place.

I haven't blogged in here much lately because I was recently diagnosed with breast cancer and I've just (today even) gotten a letter from one of those "death" panels. Amazingly, I wasn't shaking when I got the letter. They are called Medical Councils here and they determine whether someone is eligible or not for 100 percent medical coverage provided by the state, due to a prolonged illness that is in no way the fault of the patient.

This "Council" provides an essential service that is desperately needed in the US. It makes a decision about a patient's health that does not depend upon considerations like age, income, pre-existing conditions or lifestyle. The council has only one question to answer: does the patient have an illness (or trauma) that requires long term treatment? If the answer to that question is yes, the person is immediately covered at 100 percent for the duration of the illness. the NHS functions in the same way, hence Hawking's extended care.

In every country, there is a percentage of the population that falls victim to these situations. Our consistent inability to provide sustained medical care to these people regardless of income is the main reason we are a country that spends the highest percentage of our GDP (16 %) on healthcare of any developped country while maintaining the highest unnecessary death rate among these countries.

Let's stop the hype and starting looking at the facts.

The New EU President: Undoubtedly Saner than the Last, but What Will He Do?

2009-07-01T20:47:30Z

Another six months has elapsed and the permanent catastrophe that was the EU Presidency under the Czech Republic has finally ended. We now officially have a President whose government is not in danger of collapsing during his tenure. Brussels is breathing a sigh of relief tonight.

And Sweden's agenda is indeed a vast improvement on the last one, which was more or less reduced to public relations damage control once Mirek Topolánek's government actually failed: the new President Fredrik Reinfeld has vowed to tackle climate change and the economic crisis, two laudable and pressing missions.

But it's worth noting that the rotating EU presidency is schizophrenic by nature and the nuttiness of the previous president did little to actually worsen what is already a deep schism within Europe: the one that exists between countries who developed their economies from their own natural resources (and have large agricultural components even today) and those who developed their economies through trade and commerce.

France, Spain, Italy and to some extent Germany fall solidly within the former category. So not surprisingly, they support a highly regulated system of commerce which protects often fragile local economies (yes, in France we can buy milk from 15 cow farms in the Alps).

The Netherlands, Sweden and the UK developed as trade empires, and they are today all strong supporters of economically liberal policies (destroying trade barriers, opening up markets globally and allowing markets to regulate themselves).

So even though we in Europe are happy to see a new president, he might try and promote an economic agenda sure to frustrate large swaths of Europe, and the endless tug-of-war, a struggle that often reduces the EU Presidency to six-month long exercise in conflicted and unfinished policies, will continue.

Banning the Burqa in France: A Step in the Right Direction or a Political Tool?

2009-06-26T12:50:51Z

Nicolas Sarkozy traveled to historic Versailles this week to addres a double session of the French Congress (the first time this has happened since the nineteenth century) in order to call for a number of reforms (especially in the public sector). Many of his proposals are sure to anger the Socialists here. But to make the pill a bit sweeter, he offered an olive branch to his leftist opponents: he came out strongly against the burqa, the full-length Islamic garment that covers a woman from head to toe.

If this proposal sounds familiar, it is because it is. Headscarves were banned in public schools here in 2004 under Sarkozy's predecessor Jacques Chirac, in a move that was declared by both parties to be a victory for women.

In fact, coming out against various Islamic practices, mostly concerning the female sex, has proved a useful political tool for ruling politicians here. 70% of the French population supported the headscarf ban and the bill unsurprisingly gained bi-partisan support. In fact, aversion to Islam seems a defining element of the French voting base, for while not everyone in France is secular, the French are fiercely protective of the secular state and are generally confused about how to allow Muslims to practice their faith while having little or no impact on French society.

Sarkozy appears to have aimed well yet again (he was Minister of the Interior during the previous debate on headscarves): a bi-partisan bill has been rapidly introduced in parliament here banning the burqa. but are these repeated attacks on Islamic practices concerning women a step in the right direction or a subversive culture war that could have unexpected consequences?

I'm no advocate of the Burqa, but I know a political unifyer (the opposite of a wedge issue) when I see one.

There is no easy solution to this problem, but French politicians, it seems to me, are playing a delicate and potentially explosive game: waging an under the radar culture war (disguised as a womens' rights campaign), in a bid to protect traditional French secular values.

The Detainee Abuse Photos: What does Europe (and their Muslim populations) think?

2009-05-14T10:00:46Z

As an American, I know we are engaged in some serious soul searching about the Bush administration, and the firestorm over the detainee abuse photos is the latest symptom of this: the press has been apoplectic about the reversal of course by Obama. Abandoning any pretense of mediation or neutrality, the gloves have come off on a lot of news websites. TPM itself is one of many press organs to unleash the ultimate press weapon of the moment: comparison to Bush.

So what do Europeans and their Muslim populations think of all this? They loathe Bush and were fierce critics of the Iraq war. Their media have duly and faithfully reported on the firestorm surrounding the photos. You might think they'd be clamoring for full disclosure. But if you look at comments to any given article on the subject in say, Le Monde, or the BBC, you'll find that the commentators overwhelmingly side with Obama.

The reason? It might surprise Americans to learn that many Europeans and many muslims think that the media is just looking for a sensationalist photo shoot to increase their ratings. Now before anyone hits the comment button to castigate the folks in Europe who know nothing of our society, think of their perspective.

There is a basic cynicism and mistrust of the media here that is precisely the mirror image of our traditional hostility and cynicism toward government in the US. So what Americans see as a return to the abusive and secretive ways of Bush, Europeans, many of whom are Muslim, see as a blatant commercialization and exploitation of the suffering of others. It is far more apparent here in Europe of how Muslims view these images in general. For them, Americans are flaunting their abusive power over a proud and ancient people who have lost so much already. There is a good chance populations in Afghanistan would see it this way too.

This doesn't mean of course that many here don't believe the photos should be aired. On the contrary, they think they should be made public, but in the context of a courtroom. What they don't understand is that in the US, public opinion has to be swayed before anyone ends up in a courtroom.

I guess it all depends on your perspective when it comes to these issues, but I think Americans would be wise to consider how this is playing out on the world stage and not just in the the context of the political and social situation in the US.

Did the Politics of the "Empty Chair" Work at Durban II?

2009-04-26T20:40:44Z

Now that the dust has settled from the Durban II conference, (the envoys who walked out are mostly back home, the protestors silenced, the chatter waning), I think one question should now be put on the table: Was the decision to boycott the conference an effective diplomatic gesture ?

This all depends on who you ask of course, and what is meant by the word "effective." On one level, it seems like the only decent thing to do. Boycotting is also an unequivocal gesture. No one can really misunderstand the meaning of a boycott in such a setting.

But I recently spoke with one of the envoys who walked out of Durban II during Mr. Ahmadinajed's hateful speech and he said something I thought was worth mulling: "The politics of the empty chair isn't effective, because it's much easier to say hateful things to an empty chair. But if the Israeli ambassador is sitting in front you as you say it, then it becomes far more difficult. Then everyone really sees you."

Now I don't know what the correct diplomatic response is to the Iranian President's persistent habit of spouting hateful, racist idiocies in international forums and I know there are some who will argue that he would only relish the chance to humiliate Israel to its face, but I wonder who would really be humiliated and discredited in a situation like that, the person who came to listen or the one who came to spout insults and lies? In other words, I wonder if Ahmadinajed doesn't feed off of these pre-emptive protests as a way of "demonstrating" to his allies that the West "mistreats" him.

Is this is the case, would the the US and Israel's presence at these little occasions strip him of an important propoganda tool (or on the contrary embolden him?) Something to think about....

Has Obama's election made France a schizophrenic ally ?

2009-04-16T20:23:16Z

The Economist had an interesting blog today about Sarkozy at the G20 summit and his recent rather indiscreet bragging. Apparently Mr. Sarkozy has become proud of his summit theatrics and has gotten awfully eager to show his fellow Frenchmen that they've elected someone who knows more about running government than Obama does.

The blog also contains a link to an article by French left wing columnist Bernard Guetta who is surprisingly uncritical of Sarkozy (a man most people on the left here have compared to a fascist at one time or other). According to Guetta, French President Sarkozy now wants to distance himself from Obama in order to establish France as a rival center of economic power, a sort of "alternative" to failed American liberalism.

Now speaking as someone who has lived in Paris for several years, I have to say, this is hardly news: since De Gaulle pulled out of NATO, every French leader has wanted to establish France as a rival centre of power to the US--it's a prerequisite for getting elected. So Guetta's analysis is almost surreal, as if he were pointing out that Sarkozy lives in the Elysée palace and certainly has taste in his choice of homes. Of course, the French president wants to establish France as an alternative to American values: that's what French presidents do.

What I think this sudden love fest shows is that Obama's election has given the French a mild but persistent identity crisis. How can you be the moral and economic counterweight to a country that has just elected someone who embodies so many inherently "French" values? For Obama is a very smart man and intellectual (this is one of the French virtues) and he is African American (the French are very proud of their "egalitarian" values). Obama is also not a rampant free marketeer, all qualities a Frenchman might like to see in his or her own presdient.

My bet is that Sarkozy and the French left (as in the communist left) now find themselves on the same proverbial psychiatric couch wondering how to oppose someone they really should like very much but can't see a political future in it for them if they do. Sarkozy wants credit for anticipating the financial collapse (and for opposing US capitalism) and the French left here want to crow about the failure of the free market. How can you do this while embracing the president of the most capitalistic country in the world?

It'll be interesting to see how much psychology Clinton and Obama will need to get this ally off the couch and onto the negotiating table when more is needed of France in the economic crisis.

How European politics can impact US policy

2009-03-29T13:58:28Z

I was at an event in Paris recently entitled "Barack Obama's first 100 days." Despite being sponsored by the University of Chicago, the conference was in French and largely addressed a French audience. I was struck by something one of the French panelists said during this round table, when someone pointed out that Americans seemed uninterested in things French or European: "Well," the panelist said, after a pause, (and as if this was true but irrelevant), "We (the French) are standing on the balcony of history after all, watching you, the players (meaning us, the Americans). Why would you look up at the audience?"

Why indeed? Well, I think the panelist was trying hard to ignore something that is more and more obvious and that Barack Obama's coming visit to Europe will undoubtedly highlight: Europeans might be standing on the balcony, but their leaders have been on stage for quite some time. Their playbook (at least recently) was largely choreographed by George W. Bush. Obama has his work cut out for him.

Ever since the fall of communism, Europe, instead of coming together and forming a culturally and political cohesive entity, has, in one of the more ironic turns of history, splintered along the same lines that had been artificially imposed by the USSR. I've touched on this in recent blogs and got a little flak for pointing out how unpopular bailout is in Europe because of flagging Eastern European economies. But bailouts on a European scale are also unpopular for another reason: George W. Bush shunned his longtime Western allies in 2003 and embraced the former communist countries. This was a slap in the face to Western European countries and they are still massaging the bruise today.

Fair enough one could say, but the past is the past. You get over these things and move on. But this was no ordinary slap. Bush's administration (and it's debatable how much they knew about the riffs) were essentially capitalizing on a long series of mutual disappointments that had slowly riven Europe. It's common knowledge now that after the honeymoon period in the early 1990s, Eastern Europe was shell shocked by what rapidly came to be considered Western shallowness and egotism. Having been deprived of the dizzying array of choices that characterize market economies, Eastern Europeans had long cultivated a kind of warmth and affection for the past, for their poetry, literature and languages and they had developped a keen sense of social solidarity with one another. In many ways these societies were very rich culturally, despite the five year plans and bleak architecture.

And in counries with secret police who are this active, people learn to look between the lines and judge one another. So it's understandable they would be blinded by the glitter of capitalism and find it hollow.

The West by contrast had its own set of shocks. First hailed as saviours, they were miffed to discover that the East found them boorish and egotistical and they thought it was incredibly naive of Easterners to expect so much depth from McDonald's and Luis Vuitton. Easterners seemed maddenly incurious about where to look for cultural and depth and they showed visible disdain for the "flashy" materialism of Westerners. Both found the other naive and ungrateful in a way. Add to this, the real economic strain Eastern economies suddenly imposed upon Western ones and you have a situation ripe for exploitation by outside observers.

So when the Iraq war came up and the ally needy George Bush began to look for friends in unlikey places (anyone remember George Bush's famous 'You forgot Poland' remark when Kerry criticized the Iraq war coalition?), Europe suddenly fell off the balcony in a nasty family spat that Obama's election has only accentuated.

For anyone following the European response to this, you'll remember that when the Vilnius Ten, publicly pledged its support for the US in 2003, Western Europe (mainly France and Germany) awoke from its spectator like drowse and Jacques Chirac, in one of his more spectacular overreaching (and overbearing) moments, cuffed the East in a somewhat humiliating public putdown on the international stage. The French president publicly stated (in a sentence that has become legendary here) that Eastern Europe had just wasted a golden opportunity to keep its fat mouth shut (I'm really not exaggerating) his rhetoric was that strong.

Well, not alot has changed since then. Eastern Europe is still a darling of conservative right wing groups. Czech Prime Minister (and sort of EU President) Mirek Topolanek gave a speech at the Heritage Foundation in February. Reading his speech is like going back in time, to those days when Saddam's "threat" to the West was supposed to mean something. France and Germany are still smarting from having been shunned and criticized by the US, and they have embraced Obama with a kind of gusto that can only mean they want to send a message as well to their Eastern brethren who have been rather cool to Obama and nostalgic about the good old days when neoconservatives were proud of their name. Many Eastern European politicians are downright disappointed and shocked that someone like Obama has been elected. Does anyone remember the far right Polish legislator who called Obama's election "the end of white civilisation?" (the Polish government subsequently condemned his remarks).

It will be interesting to see how Obama navigates all of this during his trip and if he will succeed during his presidency, in mending some of these divides. Looks like post partisanship might come to have meaning over here as well...

Why Americans Should rethink Europe: It's like NAFTA, it's not a country

2009-03-27T11:26:33Z

Yesterday I blogged in this post about Josh Marshall's contention that (grosso modo) the EU President is a nut case for saying Obama's bailout plan is a road to hell. Mr. Marshall has a valid point even if I believe the question is more complex, and I said as much. The crux of the problem is that while Europeans generally support Obama's plan, European governments are more reluctant to launch its own trailblazing bailout scheme on a grand scale because it's very reticent to throw money at Eastern European former communist countries, whose economies are deep trouble and who have already taken billions of euros in EU aid.

But some found my posting to be elitist. TPM Reader blowagasket blows a gasket over this:

Correct me if I'm wrong: The EU expanded to include the Czech Republic for a reason, right? So, what was the reason?

Yet you and Josh Marshall both give the distinct impression that some Europeans are better than others. (Phrases like Mr. Topolanek is a symptom of a broader attitude and not simply a spoiled boorish politician who lacks even the most basic sense of tact and finesse and who most Europeans wish would simply disappear and Folks in Western Europe are really tired (that is to say, we've sort of had it) with bailing out folks in Eastern Europe and politicans like Topolanek, who are sitting in that strange no man's land between East and West give me that impression, anyway.)

It seems the member states should have foreseen such elitism and management problems before expansion.

This assertion does not address the substance of my posting nor of Mr. Marshall's remarks. Blowagasket assumes I'm disparaging my President who happens to come from one of "those" Eastern regions that aren't as European as me. But Europe is not a country. There is no real cultural and political entity called Europe-- the continent is a loose economic community much like the countries of NAFTA. It has to date no viable constitution, no enforcable laws that extend across all member countries (only regulations which are economic in nature) and its leaders (none of whom are elected by a European electorate, but are voted in by respective countries) like to play economic chess with its size. No voters in France decided or didn't decide to admit the Czech Republic. This is decided by the European Council. My ire with Mr. Topolanek (and my explanation of the reticence to want to bailout other Eastern European countries) has nothing to do with his roots or his country of origin. So I contend there is nothing elitist in finding Mr. Topolanek does not speak for me and that his words were, at best, poorly chosen.

And I think it's worth noting that the EU President doesn't speak for Europeans in the same way Obama speaks for Americans. His remarks were the worst kind of populist pandering, both to other European member states, who remained nonplussed, and to Obama's political enemies, who seem only too delighted (and ignorant of what a flop Topolanek's remarks were here). Do Republicans know that Topolanek denied parts of his speech afterward? (this is possible because the speeches are translated and the more inflammatory comments were blamed on translation error). According to French translators (all of whom, it turns out, have the precisely the same linguistic fantasies), Topolanek said that the US would fund its bailout through wordwide arms sales. This caused so much alarm that Topolanek had to immediately backpedal. It's also worth noting that he has made controversial statements about the holocaust, and doesn't hesitate to embarrass himself or his country for the sake of provocation.

In short, I think Americans should consider Europe as a continent with over 20 different languages and 27 sovereign governments, each with its own army and passport color. Obama's challenge will be to convince all these countries to pour money into an entity that, as of yet, cannot even ratify a constitution nor find a common language.

A little perspective on Josh Marshall's blog about the crazy EU president

2009-03-26T22:16:03Z

Josh Marshall recently wrote in this post about the strange case of Mirek Topolanek, currently the EU president who recently described Obama's bailout plan as a road to hell.

This prompted TPM reader artappraiser to admonish Mr. Marshall in this post, and to make the assertion that Mr. Topolanek is in fact somehow speaking, if not for Europeans, then for European governments, who aren't so keen on throwing money at the global recession in a Keynesian fit of action.

Well that got alot of people talking, some of whom rightly pointed out that Europeans already throw public money at their economies even when they're doing fine, and others who seemed to agree in some way or another with artappraiser's basic premise, namely that Europe is alarmed at this spending and that Mr. Topolanek is a symptom of a broader attitude and not simply a spoiled boorish politician who lacks even the most basic sense of tact and finesse and who most Europeans wish would simply disappear.

Neither artappraiser nor Mr. Marshall are wrong in a way, but there is a piece missing to this puzzle, namely basic awareness of the political landscape over here. The Czech Republic is on the frontier between Western Europe and Eastern (i.e. former communist) Europe. Folks in Western Europe are really tired (that is to say, we've sort of had it) with bailing out folks in Eastern Europe. Economies like say Latvia, have already received billions of euros in EU aid and just keep coming back for more. Now this isn't like California bailing out Alabama. Most Western Europeans haven't the slightest feeling of solidarity with these countries and only see them as foreign powers who show up in Brussels hat in hand and run back home without even a thank you, nor a promise, much less a plan, as to how to account for the money. I doubt many Americans would take kindly bailout money being shipped to places like Panama or Equador, even if the economies needed it, and watching it disappear without so much as projection or balance sheet blown our way.

So, politicans like Topolanek, who are sitting in that strange no man's land between East and West, and who are eager to show strength and solidarity with Western Europe, are only too eager to show how averse they are to bailout plans (and it doesn't hurt to court a few right wing American politicians while you're at it). But Josh Marshall is not wrong to point out that the EU president has way outstepped his reach. Obama's plan is widely thought to be necessary in France and in Germany and Sarkozy and Merkel are both trying to pledge support to Obama (which is a popular move) and find some way to pump money into the European economy without enraging a population that is already hurting and watching tax dollars flow away to nebulous propped up governments (now Americans can certainly understand that kind of rage right now I think)...

Sound like a strange inverted AIG scenario to anyone? It is very much like that, and it's on a continental scale...

California, the new epicenter of the Democratic party?

2009-03-03T21:16:55Z

According to this piece by Lexington in the Economist, it's not Chicago, but California that has become the new epicenter of the Demcratic party. As evidence, the author cites relatively recent power grabs in Congress--first and foremost by Nancy Pelosi, who won the speakership over the moderate Texan Martin Frost. But Californians also control most of the important committees in the House now, like Energy and Commerce, Education and Labor. Not a bad sweep for a single state, even if it is already pretty big and populous (but as Texas now knows of course, it takes more than geographic size and population to seize important chairmanships in Congress and affect policy).

So the question the author asks, and I think it's worth considering, is whether the Democratic party is in danger of being "captured" by California, which has a progressive social agenda, but has pitfalls as well (witness the dysfunctional politics), in the same way the Republicans were "captured" by the South and became a regional party.

The market and healthcare

2009-02-26T22:33:41Z

Back in November, I posted a 3 part interview with a European health expert who discussed with me some of the reasons why American healthcare is crippled. Our last interview focused on why market regulation of healthcare doesn't work. My blog had a remarkably short life on the TPM site because I posted on the day of the election (November 4). Suffice it to say, we had other things on our mind that day!

The subject is receiving new attention now and I'd like to re-post parts of the intervew here. My health expert and I have modified and essentially updated the information so as to make it a nearly brand new interview. It's an incisive look at American healthcare from a reasonably objective outside expert.

Blevins: Why hasn't market regulated private healthcare worked in the US?

François: The big problem with private healthcare is that it not comprehensive enough, so it is ineffective.

Take the pharmaceutical industry for instance, its money is just like Wall Street's money, and just like what happened to Wall Street, speculation has driven prices up to artificially high levels. By this I mean the price that consumers pay is absolutely not justified by the cost of drug production, or by the return investment shareholders can reasonably expect, not even by the risks tied to production (i.e. for every drug you produce you have others that fail so you have to include this in the price of the successful drugs).

These factors do not really determine current prices at all. Rather, they are fixed by the demands of stockholders who, driven by a desire for profit, push the company to determine its prices based solely upon the material desires of the shareholders and the company's stock market value. So prices skyrocket because the real factors that should determine their value are discarded for the volatile and fabricated values of stock market demand.

Blevins: Some would argue that the market hasn't done so well lately but that it still has the capacity to regulate the price of medecine properly, if the market itself is regulated properly.

François: In the healthiest market in the world, with all the right regulations in place, this is still impossible. Let me explain. In order to do it, I must go back to something that happened during the campaign. McCain wrote in a medical journal that healthcare should be deregulated (like the markets). He got a lot of flak for that but if I understood him correctly, what he meant was that he wants healthcare policies to compete across state lines.

On the surface, this isn't a bad idea. Private healthcare does have a real benefit and McCain knows this very well. When you have identified a risk for the individual, say smoking for instance, only private insurance has the flexibility to force its policy holders to improve their health habits (i.e. if the individual continues to smoke the insurance company has the right to raise his or her premiums). McCain's desire to let insurance companies compete would seem to provide the necessary market competition (thereby reducing premiums) while allowing insurance companies to more or less motivate healthy behavior. So McCain (and other politicians like him) are making a point that seems valid, but upon inspection it doesn't hold up or even make sense in this industry for one very big reason: these cases of identifiable medical illnesses with 100 percent prediction of risk (the only ones that can be effectively controlled by market regulation of healthcare) are statistically insignificant.

The vast majority of health problems result from causes that are not known and thus not measurable by any objective criteria (accidents, genetic problems that are currently undetectable before adulthood, most cancers) all these health risks are not measurable like you can measure the risks of smoking. So it makes absolutely no sense to promote a healthcare plan based upon criteria that apply to less than 10 percent of your country's medical problems. You have to provide some kind of minimal coverage that does not depend upon individual behavior if you want to avoid a massive breakdown in healthcare. This is precisely what the US is now experiencing. So even though you make great technological advances in medecine, your actual performance has been effectively blocked by market considerations, causing you to invest large amounts of money, even while your avoidable death rate rises at an alarming rate. It's very simple. Most health risks are not measurable and any market regulation will assume that they are measurable and thus controllable.

Let's hope your faith in the free market, which isn't entirely missplaced, can be tempered enough to allow you to implement an effective healthcare system.

American Healthcare, part III: Why the market isn't helping

2008-11-03T14:45:25Z

Good morning from Paris. Welcome back to our ongoing conversation with a public health expert in Europe. This is the final installment of a three part conversation on the American healthcare system. Today we discuss market regulated healthcare, its advantages (it does have some according to our expert!) disadvantages, and why Obama's plan is workable and realistic.

(These conversations were held in October at Mr. François Paris offices. I translated them for this blog).

Blevins: Why hasn't market regulated private healthcare worked in the US?

François: The big problem with private healthcare (and with McCain's plan) is that it not comprehensive enough, so it is ineffective.

Take the pharmaceutical industry for instance, its money is just like Wall Street's money, and just like what happened to Wall Street, speculation has driven prices up to artificially high levels. By this I mean the price that consumers pay is absolutely not justified by the cost of drug production, or by the return investment shareholders can reasonably expect, not even by the risks tied to production (i.e. for every drug you produce you have others that fail so you have to include this in the price of the successful drugs).

These factors do not really determine current prices at all. Rather, they are fixed by the demands of stockholders who, driven by a desire for profit, push the company to determine its prices based solely upon the material desires of the shareholders and the company's stock market value. So prices skyrocket because the real factors that should determine their value are discarded for the volatile and fabricated values of stock market demand. McCain doesn't seem to think it is a problem to divorce a product's price from concrete factors like the cost of its production or reasonable profit expectations. We have seen with the stock market that it can be a very big problem.

Blevins: So how is Obama's plan better ?

François: This is where the government has a role to play and this is something Obama and his advisors understand very well. The government doesn't have to control every aspect of healthcare, but it has to be able to regulate prices, so that the price of drugs and treatment always corresponds to the basic criteria that should go into determining the value of any product: its cost of production and the reasonable return on investment by shareholders. McCain doesn't address this issue at all in his plan. Obama does in a part of his plan called the Health Insurance Exchange.

Blevins: But how exactly does an Obama administration go about regulating healthcare and not just the pharmaceutical industry?

François: This is a good question and it hits at the heart of McCain and Obama's differences of perception. McCain recently wrote in a medical journal that healthcare should be deregulated. He got a lot of flak for that but if I understood him correctly, what he meant was that he wants healthcare policies to compete across state lines.

On the surface, this isn't a bad idea, but this kind of policy is doomed to failure for one essential reason: McCain is making a point that seems valid, but upon inspection, doesn't hold up or even make sense in this industry.

Let me explain: private healthcare does have a real benefit and McCain knows this very well. When you have identified a risk for the individual, say smoking for instance, only private insurance has the flexibility to force its policy holders to improve their health habits (i.e. if the individual continues to smoke the insurance company has the right to raise his or her premiums). McCain's desire to let insurance companies compete would seem to provide the necessary competition (thereby reducing premiums) while allowing insurance companies to more or less motivate healthy behavior.

But McCain and other healthcare providers for years have refused to face a simple reality: these cases of identifiable medical illnesses with 100 percent prediction of risk (the only ones that can be effectively controlled by market regulation of healthcare) are not statistically significant. The vast majority of health problems result from causes that are not known and thus not measurable by any objective criteria (accidents, various genetic problems that are currently undetectable before adulthood, most cancers) all these health risks are not measurable like you can measure the risks of smoking.

So McCain is essentially selling a healthcare plan based upon a theory that can apply to less than 10 percent of your country's medical problems. You have to provide some kind of minimal coverage that does not depend upon individual behavior if you want to avoid a massive breakdown in healthcare. This is precisely what US is now experiencing. Your technology has advanced, but your actual performance has been effectively blocked by market considerations, causing you to invest large amounts of money, even while you avoidable death rate rises at an alarming rate.

Let's hope your faith in the free market, which isn't entirely missplaced, can be tempered enough to allow you to implement an effective healthcare system.

In November, I will be blogging on the different Images of America that abound in Europe.

American healthcare seen from Europe, Part II

2008-11-02T13:42:48Z

Welcome back to the second part of a three part conversation about American healthcare with a public health expert here in Europe. Many thanks for the helpful comments about Part I. My subject, who has agreed to let me call him "Mr. François" is following closely as well and hopes to respond to some of these comments after our final interview together.

The topic of our second conversation was more specifically about the role that pharmaceutical companies play in both Europe and in the US in determining the cost of medical care

(NB: market regulation of healthcare is the subject of our final conversation though I indicated yesterday that it would be part II. My apologies!).

In this session, I was interested in knowing why the same medicines are more expensive in the US compared to Europe and how this affects the global drug market. Also, why doesn't the market regulate costs of medicine effectively? And finally, how is Obama's plan for regulation of drug prices better than McCain's? Since my subject works for a large pharmaceutical company with a market both in the US and in Europe, I felt he was in a good position to respond.

Blevins: Why is medicine so expensive in the US?

This is a very good question. The main difference between the US and Europe is that in the US, healthcare in general, and thus drug access and price, is based upon the patient's ability to pay whereas in Europe these costs are based upon patient need. In other words, the state, like any client, will always negotiate prices that will allow it to pay for large segments of the population in the most efficient way. It's like buying in bulk if you will. Individuals don't have this power. Individual capacity to pay (and not need within the population) determines prices. This means that both the cost of care and the cost of administering medical care rise at a much faster rate in the US.

Blevins: I see how the government can force cheaper initial prices for medicine and for care, but I don't really see how this makes costs rise over time.

Let me explain. In the last 10 years in the US, your annual inflation has been around 8 percent. But your drug prices (are you ready for this?) have risen 80 percent. This is because there are many competing companies and no central regulating agency which can step in when these companies start speculating on prices. In other words there is no entity that can control price inflation.

And there's more, the absence of a central regulating agency within your healthcare system has caused administrative costs to skyrocket, because, since all these companies are in direct competition, they spend exorbitant amounts on marketing and don't share any of the administrative costs of healthcare. Each company reinvents the wheel if you will, developing basically the same types of drugs and care without cooperating at all. That's incredibly inefficient and takes a real toll on the consumer, who pays for all this.

Blevins: Since most pharmaceutical companies are multi-national, does this affect the price of medicine globally?

Absolutely! Most pharmaceutical companies, even if they have headquarters in other countries, also have an affiliate in the states. Since medicine in the states is so much more expensive, they index the cost of different drugs by using the price in the states. This means that although other countries get lower prices for the same drug, globally the company tends to maintain relative homogeneity in the price. This pulls up drug prices globally.

Blevins: I'd like to turn to the candidates' plans as a way of wrapping up this second interview. How does Obama address drug costs in his plan and why is his response better than McCain's?

Obama's plan is superior for one fundamental reason. Both McCain and Obama agree that drug prices are rising too fast but the essential difference between both programs lies in the federal price negotiation: should we negotiate (or not) prices with drug manufacturers and define reference prices? Obama says yes because he and his advisors realize that the market is too volatile to prevent market inflation of the cost of medicine.

In our final conversation we discuss why market regulated healthcare in the US has not been successful and whether or not this is inevitable in a society with private healthcare. We also take a final look at the candidates' plans.

American healthcare seen from Europe

2008-11-01T12:30:24Z

I live in France and am a beneficiary of socialized healthcare. This is a system that certainly has its own set of problems but the difficulties are not, in my opinion, nearly as severe or widespread as the problems in the US.

I recently sat down with a public health expert in Europe who now works for an international pharmaceutical company. He wishes not to be named but was willing to speak about American healthcare. He has read both Obama's and McCains health care plans. I asked him what he thinks of the American healthcare system and what he thinks of private healthcare. Here is one of three conversations we had on the subject.

Blevins: What shocks you most about the American healthcare system?

The most shocking aspect is the ratio between cost and efficiency. If you look at it from a purely statistical viewpoint, this is quite striking. In 2006 for example, 16 % of your GDP was spent on healthcare, an enormous investment, yet in a recent study that assesses the quality and performance of health systems over time in 19 OECD countries, the US was last. If your automobile industry were this inefficient, the US would probably not even qualify as a G8 country.

Blevins: Does this mean that the quality of healthcare in the US is really that poor? Because Americans are mostly concerned about the cost of their healthcare, but there is a widely held belief that we have the best medical facilities and doctors in the world.

Well Americans are both right and wrong about this. Because it's true, most of the top ten medical centers in the world are in the US. This seems like absolute proof of American healthcare quality. But your ability to perform has not kept up with your technological and medical improvements. For instance, when you compare the first analysis of this report, taken in 1997 with results from 2003, you see a definite trend: other countries have made big improvements in the performance of their healthcare systems, compared with the US, whose system has made only marginal gains. So the US has fallen behind the other OECD countries because it has been unable to move forward and adapt to the changing conditions within your country.

Blevins: Does this mean these facilities are only available to the rich?

Not exactly. The problem is more complex than this. Let me explain this using the previous example: if you take the above report I mentioned and you leave out the US, the curve tracking healthcare system improvement is quite steep. And if you take this curve and you apply it to the US in order to determine how many deaths could have been avoided, you find that no fewer than 75,000 people died needlessly in the US in 2002 and 2003 for instance. That's a staggering number of avoidable deaths.

Blevins: So what are the real differences between healthcare in the US and healthcare in the top ranked countries in this report?

The top countries were France and Japan. They were the first when the tracking started in 1997-98 and they still are the top ones five years later, in 2002-03. What is interesting is that these two countries' healthcare systems are completely different, but they have one thing in common: in both countries, the state intervenes in two key areas, in the cost of medicine and in the funding of treatment for serious and prolonged medical conditions (cancer, diabetes and MS for instance)

Blevins: How does the state intervene in these two areas and why is that better than the American system?

Well in the US, the market determines the price of medicine and the price of major medical treatments. In concrete terms this means that new drugs are much more expensive in the US than in Japan and in France. And often a high co-payment is demanded of the patient. It's the same when it comes to treatment for prolonged medical treatment: since the market determines cost, it tends to be quite high and this heavy cost delays access to care, which results in higher mortality. In other words, the market creates impossible conditions for effective and rapid treatment.

This is nothing new of course but the American system is particularly problematic because American capitalistic regulation is based on the idea the individual has a choice and that he or she can at all times exercise this right. But when you're in need of medical attention, your bargaining capacity is radically altered. You have no choice but to seek treatment and this means the individual has very little room for bargaining. In France and in Japan, the state assumes the role of negotiator and acts on behalf of the collectivity to regulate costs.

In the next conversation, I ask our expert why the market is unable to regulate prices effectively.