France-Etats-Unis: L’autre chassé croisé des dépenses de santé (Health costs’ triple whammy)

SickoCoût total deux fois plus faible (3000 dollars/habitant) contre médecins deux fois plus payés (5 fois le salaire moyen), coûts sociaux du travail plombant les entreprises et les chômeurs contre coûts élevés d’étude et d’assurance pour les médecins et forte proportion de non-assurés …

Intéressants articles, dans la presse outre-Atlantique et au-delà des outrances habituelles d’un Michael Moore, sur le débat américain actuel autour des problèmes d’assurance médicale.

Et ce non seulement dans la perspective de l’élection présidentielle américaine de l’an prochain, mais aussi par rapport à notre propre débat français (voir aussi l’article du Figaro ci-dessous) sur l’explosion des déficits de la Sécurité sociale.

Et surtout, à nouveau, pour l’impression de chassé croisé (vers une éventuelle convergence?) auquel on assiste.

Les Etats-Unis commençant à s’orienter (au moins dans certains états comme la nouvelle expérience tentée au Massachussets, l’état du candidat Romney) vers une certaine couverture universelle (vieux cheval de bataille d’une autre candidate: une certaine… Clinton!) et possiblement obligatoire (que la France elle-même n’avait pas jusqu’à très récemment avant la CMU des gouvernements Juppé puis Jospin).

Tandis que la France elle-même commence (doucement, vu le tollé soulevé par l’idée de franchise médicale) à se rendre compte de l’insolvabilité chronique et de l’injustice de son propre système étatique.

Mais, couverture universelle ou pas et au-delà des parti-pris idéologiques et du problème des petites entreprises ou des services (en France même, comme vient de le révéler tout récemment un rapport, un quart des cafés, restaurants, hôtels fraudent l’URSSAF), il est clair que le véritable problème, comme l’Amérique elle-même est en train de s’en rendre compte, est surtout, pour la majorité des déjà-assurés, celui de la logique explosion des coûts médicaux et partant des assurances à laquelle il faudra bien effectivement un jour s’attaquer.

Et ce en même temps et du fait même de l’explosion concomitante des exigences (de succès mais aussi contre les risques!) du côté des patients que nous sommes et du traitement de toujours nouvelles et plus coûteuses affections.

Si bien qu’on a affaire à un véritable cercle vicieux: avec la meilleure couverture médicale, la longévité s’accroit et nos populations vieillissent (surtout ici en Europe), d’où l’allongemnt de la période où d’utilisation maximale des services médicaux et la croissance continue des gens qui en auront besoin.

D’où la nécessité d’avertir les gens et contribuables dès maintenant qu’à moins d’une augmentation drastique de notre démographie (le retour à des familles de 3-4 enfants ou plus?) ou de l’immigration (avec les autres problèmes que ça entrainerait).

Et qu’à défaut de revenir au système primitif d’abandon de nos personnes âgées (sous l’appellation modernisée d’euthanasie – même si on pourrait aussi faire quelque chose par rapport à l’acharnement thérapeutique) et au-delà du rationnement des soins moins vitaux (existant déjà de fait ou explicitement dans les systèmes américain ou britannique).

Il faudra bien envisager un jour très prochain une augmentation conjointe des versements d’assurance, de l’épargne individuelle et des prélèvements publics (impôts, charges sociales) si on veut limiter le nombre de ces faillites et tragédies personnelles ou, comme en France, éviter de repousser les déficits indéfiniment pour nos enfants et petits-enfants!

Mais aussi probablement avertir les candidats au divorce ou déjà les (futurs) jeunes mariés que la liberté illimitée (y compris en amour!) a aussi un coût, d’où les inévitables sur-risques financiers et personnels que peut provoquer un divorce quand on se retrouve avec une seule assurance et que les coûts explosent …

Le rejet d’une augmentation du financement de la santé par nos concitoyens assez largement partagé, est paradoxalement associé à un haut niveau d’exigence vis-à-vis de la médecine, avec une demande de réussite thérapeutique maximale et un niveau de risque zéro. Cette exigence a d’ailleurs un coût, puisque pour se protéger des plaintes, les praticiens sont amenés à multiplier les examens complémentaires parfois inutilement.

Actuellement 140 milliards d’euros sont investis dans les dépenses de santé, avec une croissance de 2 milliards chaque année. La prise en charge de la maladie d’Alzheimer – dix milliards d’euros par an – devrait coûter encore plus cher, si l’on considère que le nombre de malades va s’accroître et que des thérapeutiques innovantes vont arriver sur le marché. Le coût du cancer, c’est 11 milliards d’euros par an. Il y a encore quarante ans, les traitements se limitaient à la chirurgie et/ou à la radiothérapie. Et finalement, ou bien les malades étaient guéris, ou alors ils mouraient rapidement.

Les choses ont changé, un million de personnes vivent avec un cancer dans notre pays et 280 000 nouveaux cas apparaissent chaque année. Ces chiffres ne font qu’augmenter. Le cancer est considéré désormais comme une maladie chronique avec laquelle on vit longtemps, moyennant une surveillance et éventuellement des chimiothérapies à répétition. Des nouveaux médicaments anticancer arrivent à des prix très élevés. L’herceptine, contre le cancer du sein coûte environ 26 000 euros par an et par malade, en plus des autres thérapeutiques. Le Glivec est une molécule efficace contre les lymphomes moyennant 3 000 euros par mois et par personne.

Les Français vivent de plus en plus vieux, il est logique que les dépenses de santé augmentent
Le Figaro
Le 03 août 2007

L’analyse de Martine Perez, adjointe au chef de service Sciences et Médecine du Figaro

Nicolas Sarkozy a donc choisi « pédagogiquement » d’annoncer d’abord un plan de lutte contre cette effrayante maladie d’Alzheimer qui concerne des millions de personnes (les malades et leurs familles) avant de révéler qu’il avait arbitré en faveur d’une franchise de 50 euros par an à payer par les patients pour financer leurs soins, en plus des cotisations de la Sécurité sociale.

Ce choix a déclenché un tollé à gauche, certains estimant « qu’une fois de plus les malades vont payer » et que ce système de franchise est « inégalitaire », selon les termes de la CFDT et de Jean-Marie Le Guen, député socialiste. Le débat sur la meilleure manière de procéder pour financer la santé ne sera jamais clos : les dépenses seront toujours supérieures aux recettes calculées approximativement, sans se projeter dans un avenir fait de techniques médicales de plus en plus performantes et onéreuses.

Personne ne peut donc faire croire aux Français, que l’on peut dépenser toujours plus, sans jamais avoir à payer plus. Or, à aucun moment du débat, le bilan du coût de la santé – qui est aussi celui d’un bénéfice de qualité et d’espérance de vie – n’est évoqué.

Un constat devrait s’imposer à tous : les Français vivent de plus en plus vieux grâce aux progrès de la médecine qui moyennant des traitements chroniques, leur évitent de tomber malades ; et s’ils tombent malades, d’autres médicaments chroniques leur permettent de se stabiliser. Cette stratégie repousse sans arrêt les limites de durée de la vie humaine.

Le rejet d’une augmentation du financement de la santé par nos concitoyens assez largement partagé, est paradoxalement associé à un haut niveau d’exigence vis-à-vis de la médecine, avec une demande de réussite thérapeutique maximale et un niveau de risque zéro. Cette exigence a d’ailleurs un coût, puisque pour se protéger des plaintes, les praticiens sont amenés à multiplier les examens complémentaires parfois inutilement.

Actuellement 140 milliards d’euros sont investis dans les dépenses de santé, avec une croissance de 2 milliards chaque année. La prise en charge de la maladie d’Alzheimer – dix milliards d’euros par an – devrait coûter encore plus cher, si l’on considère que le nombre de malades va s’accroître et que des thérapeutiques innovantes vont arriver sur le marché. Le coût du cancer, c’est 11 milliards d’euros par an. Il y a encore quarante ans, les traitements se limitaient à la chirurgie et/ou à la radiothérapie. Et finalement, ou bien les malades étaient guéris, ou alors ils mouraient rapidement.

Les choses ont changé, un million de personnes vivent avec un cancer dans notre pays et 280 000 nouveaux cas apparaissent chaque année. Ces chiffres ne font qu’augmenter. Le cancer est considéré désormais comme une maladie chronique avec laquelle on vit longtemps, moyennant une surveillance et éventuellement des chimiothérapies à répétition. Des nouveaux médicaments anticancer arrivent à des prix très élevés. L’herceptine, contre le cancer du sein coûte environ 26 000 euros par an et par malade, en plus des autres thérapeutiques. Le Glivec est une molécule efficace contre les lymphomes moyennant 3 000 euros par mois et par personne.

Voir aussi:

Covering the uninsured isn’t enough. We also must upgrade and guarantee continuous coverage for those who have insurance.

Medical coverage is becoming more for catastrophic loss than for intermediate expenses.

The study did not examine how many bankruptcy filers were from dual-income families where both partners had insurance.

Medical bills trigger half of all bankruptcies
Study finds most bankruptcy filers had health insurance
The Associated Press
Feb. 2, 2005

BOSTON – Costly illnesses trigger about half of all personal bankruptcies, and most of those who go bankrupt because of medical problems have health insurance, according to findings from a Harvard University study to be released Wednesday.

Researchers from Harvard’s law and medical schools said the findings underscore the inadequacy of many private insurance plans that offer worst-case catastrophic coverage, but little financial security for less severe illnesses.

“Unless you’re Bill Gates, you’re just one serious illness away from bankruptcy,” said Dr. David Himmelstein, the study’s lead author and an associate professor of medicine. “Most of the medically bankrupt were average Americans who happened to get sick.”

The study, to be published online Wednesday by the journal Health Affairs, distributed questionnaires to 1,771 bankruptcy filers in 2001 in California, Illinois, Pennsylvania, Tennessee and Texas. That year, there were 1.46 million personal bankruptcies in the United States.

More than 900 of those questioned underwent more detailed interviews about their financial and medical circumstances for what the authors say is the first in-depth study of medical causes of personal bankruptcies, which have risen rapidly in recent years.

Illness and medical bills were cited as the cause, at least in part, for 46.2 percent of the personal bankruptcies in the study. Himmelstein said the figure rose to 54.5 percent when three other factors were counted as medical-related triggers for bankruptcies: births, deaths and pathological gambling addiction.

The study estimates medical-caused bankruptcies affect about 2 million Americans each year, counting debtors and their dependents, including 700,000 children.

Most were insured
Most of those seeking court protection from creditors had health insurance, with more than three-quarters reporting they had coverage at the start of the illness that triggered bankruptcy. The study said 38 percent had lost coverage at least temporarily by the time they filed for bankruptcy, with illness frequently leading to the loss of both a job and insurance.

Out-of-pocket medical expenses covering co-payments, deductibles and uncovered health services averaged $13,460 for bankruptcy filers who had private insurance at the onset of illness, compared with $10,893 for those without coverage. Those who initially had private coverage but lost it during their illness faced the highest cost, an average of $18,005.

“We need to rethink health reform,” said Dr. Steffie Woolhandler, a study co-author and associate professor of medicine at Cambridge-based Harvard. “Covering the uninsured isn’t enough. We also must upgrade and guarantee continuous coverage for those who have insurance.”

Susan Pisano, a spokeswoman for America’s Health Insurance Plans, representing nearly 1,300 health insurance providers, said the study did not adequately explore the role that disability income protection plans and personal savings can play in helping someone with a medical problem avoid bankruptcy.

“It’s very important to ask questions about what the financial stressors are for American families, but we don’t think this study digs deeply enough,” Pisano said.

Middle-class hit hard
The findings indicate medical-related bankruptcies hit middle-class families hard — 56 percent of the filers owned a home, and the same number had attended college.

“Families with coverage faced unaffordable co-payments, deductibles and bills for uncovered items like physical therapy, psychiatric care and prescription drugs,” Himmelstein said.

The study, funded by the Robert Wood Johnson Foundation, did not examine how many bankruptcy filers were from dual-income families where both partners had insurance, Himmelstein said.

Jeff Morris, resident scholar at the American Bankruptcy Institute, founded by Congress in 1982 to analyze bankruptcy trends, said the Harvard findings roughly mirror those of a 1996 ABI study in which 57 percent of bankruptcy filers cited medical problems as a primary bankruptcy cause. Respondents in that study were more likely to cite three other factors as primary causes, including easy access to credit, job loss and financial mismanagement.

Morris said he was aware of no data indicating that the Harvard study, which was based on 2001 bankruptcy filings, does not accurately reflect current trends in medical-related bankruptcies.

“Medical coverage is becoming more for catastrophic loss than for intermediate expenses,” Morris said.

Voir également:

Is a good employer who doesn’t offer health insurance still a good employer? Is a person living without health insurance to be regarded as selfish, like a driver without auto insurance?

Nearly everyone has to have insurance, or else face a penalty at tax time.

Businesses with 11 or more employees have to pay a « fair share » of the cost, or they face a penalty, too.

The state has signed up more than 150,000 poor people for free or subsidized health insurance, negotiated lower-cost plans for everyone else, helped the self-employed and employees of small businesses qualify for group coverage, and required that, starting in 2009, everyone have prescription drug coverage and low deductibles so their health insurance actually helps when they get sick.

Most of our employees look at us to having flexible hours and the ability to make some good money while they’re here. And most of the employees already have insurance, either through parents or a spouse or a second job.

One of the servers at the Sea View, Maureen Linehan, 49, is a single mom working three jobs — one job because it provides health insurance for her and her 16-year-old daughter, and the other two jobs so she can pay the bills, including her share of the insurance.

Will the state be able to enroll enough young, healthy people — the kind who pay premiums but don’t get sick very often — to reach the goal of universal, or near-universal, coverage without needing a tax increase to pay for it? And even if everyone signs up, can the system be sustained if it doesn’t address the rising cost of health care?

« Most of the people in the state who haven’t gotten insurance are young, and most of those are men. »

Will the political left accept a reform that leaves insurance companies in the central role, instead of a Canadian-style system run by the government?

Will the political right accept a reform that coerces employees and employers into buying a particular product?

Mass. cooks up health care experiment
Businesses, individuals wrestle with implications of universal insurance
By Bill Dedman
Investigative reporter
MSNBC
Aug. 16, 2007

ON CAPE COD, Mass. – Grill cook David Smith is feeling pretty healthy, thank you, and he isn’t happy that the government is forcing him to sign up for health insurance — even if it may be good for him. But cook Scott Carter wishes he’d had insurance last year, when he got socked with $9,000 in medical bills.

An experiment is cooking in Massachusetts, which invented everything, or so its residents will tell you. And they can stake an honest claim for basketball, chocolate chip cookies and Technicolor, not to mention the American Revolution. Now Massachusetts is tinkering with universal health insurance. By Dec. 31, nearly everyone in the state will be required to have an insurance card.

The Massachusetts plan is a political experiment, a policy experiment, and a social experiment. It imposes a system of shared responsibility, with new burdens on individuals, on employers, and on the government. The state taxpayer association calls it « a truly noble experiment. »

In broad strokes, it works like this:
# Nearly everyone has to have insurance, or else face a penalty at tax time.
# Businesses with 11 or more employees have to pay a « fair share » of the cost, or they face a penalty, too.
# The state has signed up more than 150,000 poor people for free or subsidized health insurance, negotiated lower-cost plans for everyone else, helped the self-employed and employees of small businesses qualify for group coverage, and required that, starting in 2009, everyone have prescription drug coverage and low deductibles so their health insurance actually helps when they get sick.

For a glimpse at the plan’s effects on employers and employees, we took a drive out on Cape Cod, that spit of sand stretching into the Atlantic like a flexed arm (one bejeweled with pirate-themed miniature golf courses).

We visited two restaurants to meet the owners, cooks and waitresses, who are struggling to adapt to the Massachusetts Health Reform Law.

What’s a good employer?
First stop, the town of Dennis on Nantucket Sound, where an old restaurant family has opened a new restaurant. The McCormicks have been serving seafood for 49 years at the Ebb Tide, and now have opened a larger, less-formal restaurant just two doors away. Out on the deck, the Sea View serves pan-seared crab cakes, broiled swordfish brochette and lobster quesadillas.

By the usual reckoning, the McCormicks are good employers. The same workers come back year after year for the summer season, which the new restaurant is stretching from April to December. Many of their 60 workers at the two restaurants have been with the family a decade or more. When a 21-year-old Russian dishwasher had a recurrence of cancer, the family helped him arrange a bone marrow transplant in Boston, and he lived with the family for a full year while he recovered.

But perhaps there’s a new reckoning. With a seasonal business, the family has never offered health insurance.

« Most of our employees look at us to having flexible hours and the ability to make some good money while they’re here, » said owner Gail McCormick Knell. And most of the employees already have insurance, either through parents or a spouse or a second job.

The Massachusetts plan is a social experiment, with the potential to change how Americans think about personal responsibility. Is a good employer who doesn’t offer health insurance still a good employer? Is a person living without health insurance to be regarded as selfish, like a driver without auto insurance?

Single mom works three jobs
One of the servers at the Sea View, Maureen Linehan, 49, is a single mom working three jobs — one job because it provides health insurance for her and her 16-year-old daughter, and the other two jobs so she can pay the bills, including her share of the insurance.

« I work three nights a week at the Ebb Tide, and then I do weekends catering at the Sea View, and then I have a full-time job for a nonprofit. » Altogether, she earns about $35,000.

Linehan’s day job is in social services, as a case manager helping families find housing and deal with other problems, such as substance abuse. She said she regularly sees poor families adapting to the health insurance law.

The Massachusetts plan is a policy experiment, too. Will the state be able to enroll enough young, healthy people — the kind who pay premiums but don’t get sick very often — to reach the goal of universal, or near-universal, coverage without needing a tax increase to pay for it? And even if everyone signs up, can the system be sustained if it doesn’t address the rising cost of health care?

Since the law took effect on July 1, about 170,000 of the uninsured have signed up — but most of them are the poor. Just 17,500 or so have signed up for the unsubsidized health insurance plans through July, but those plans just became available May 1. That leaves the tougher nut: about 200,000 to 300,000 people who earn enough money so they aren’t eligible for subsidized care. They may not see the need to spend part of their disposable income on health insurance.

The state has already backed off of « universal. » About 160,000 uninsured people in the state have incomes that are too high to qualify for subsidized health insurance — but too low to afford the lowest-cost unsubsidized plans. About 60,000 of these working poor won’t face a penalty for not getting insurance, but the 100,000 others are in a bind.

« What I’m starting to see, » Linehan said, « is the people have to pay for their health care, and now they can’t afford to pay their rent. »

Linehan has insurance through the nonprofit agency but said she worries that her part of the cost will rise. « If the board decides tomorrow that they’re not going to pay the big chunk of it, I would really have to get another job. And I don’t have much more room left — I’m out of time. There is no more time left in my day to work. »

Every cost is rising, she said, but insurance costs are the ones that she fears could knock her into insolvency. Every doctor visit is $20, and prescriptions are $50 a month — on top of her share of the premiums, nearly $300 a month. « My daughter just had an operation, so my insurance covered it. I don’t know what we would have done if that didn’t happen. And I had to borrow the money for the deductible. »

« I’m one of the working-class poor on the Cape. I lucked out — I bought my condo just before the prices went up — but if anything changes, I will be one of my clients. »

Medical bills clobbered cook
Back in the kitchen, 23-year-old Scott Carter is preparing for the dinner rush. This is his 10th summer with the McCormicks, and he has worked his way up to cook.

Last winter, he came down with a stomach ailment that left him with $9,000 in bills from the resulting surgery. The hospital worked out a payment plan — $100 a month for 90 months — but that was little comfort to Carter, who was taking home only about $15,000 a year.

« I was like, I don’t know what I’m going to do, » he said. « I need help.

« And that’s when all this talk about health insurance for everyone came into play. And I was like, ‘Well, what about me? I’m everyone. Let me get health insurance.’ I’m sure to be the first person. I’m ready, pen in hand. »

One premise of the state plan is the state’s costs for health care will fall if people get preventive care. Carter said that’s certainly true in his case. « I would have gone to see the doctor, and they would have told me, ‘You’ve got to start eating right.’ I just wouldn’t have been in the predicament. I hadn’t been to a doctor’s in like six years for a checkup or a physical. »

« When I had health insurance, as a kid, I went every half a year, like clockwork. And after I didn’t have health insurance, I never went. … I feel healthy, so I imagine I am. »

He’ll soon have insurance. Businesses with 11 or more full-time employees must offer it — though it’s more complicated than that. The Sea View employees who sign up for the new insurance plans will pay most of the cost. The McCormicks expect to set up a so-called Section 125 plan (named after a part of federal law), and the employees can pick out the insurance plan they want from the state’s menu. The premiums are paid with an employee’s pre-tax dollars — that saves money on withholding taxes for the employer and for the employee. If employers don’t either pay at least one-third of the premiums, or get 25 percent of the employees to sign up, they’ll have to pay a penalty (the state calls it a « fair share contribution ») of $295 per employee per year.

Owner Gail Knell has spent hours at seminars on the new law, and it didn’t help much. « I became more confused with the seminars, because there were so many regulations. » (And she’s a professor of business at Cape Cod Community College.)

« If you’re a small business, your profit margin is very small, and it keeps getting smaller and smaller, » she said. « You know, I’m all for people having insurance. … And if we can help get it to our employees, that’s a good thing. »

But how are the employees going to pay for that insurance — if not from their salaries? In other words, won’t some employees expect higher wages, now that they have another bill to pay?

« You’re betwixt and between, » Knell said. « Do you extend your season, so that they can work more so they can have it longer and afford more? And how does that affect our business and our business decisions? »

A reluctant participant
The quiet dining room of the Sea View was a distant memory after the half-hour drive to the raucous precincts of Arnold’s Lobster and Clam Bar, a New England seafood shack near the beach in Eastham. The joint started with a « Happy Days » theme (thus the name, Arnold’s, just like on the TV show). Now the roller skates are long gone, but the clams are fresh and the onion rings piled high.

The owner answers when tourists call him Arnold, but his name is really Nathan Nickerson III, and most everyone calls him Nick. He admits to being a P.T. Barnum of the seafood shack set — he loves to carry around a 50-year-old, 17-pound live lobster « pet, » about the size of a second-grader, draping it over small children, whose eyes get big in a hurry.

Nickerson has long offered health insurance at Arnold’s, but not everyone has taken it.

Cook David Smith, 35, is one of those exceptions, and he’s not happy that the state is coercing him into signing up.

« I was moderately outraged, » Smith said while grilling burgers and assembling lobster rolls. He called health insurance « something for your own good that you’re being required to do. »

Persuading the young and healthy to join the health plan is key to its success. That’s why the state is spending $1.3 million to advertise on Red Sox cable broadcasts. « Their audience is ours, » said the spokesman for the state program, Richard R. Powers. « Most of the people in the state who haven’t gotten insurance are young, and most of those are men. »

So far, only a few thousand people a month have signed up, but the deadline is still four months away, and even then the penalty for noncompliance is weak. Those who can’t show proof of insurance by the end of 2007 lose their state tax exemption when they file their income taxes in 2008, or about $219.

The penalty increases in January 2008. For every month in 2008 that they don’t have insurance, residents will have to pay a penalty of up to half the cost of the lowest-cost plan. That could be as much as $150 a month, or $1,800 a year, due at tax time in 2009.

The definition of personal responsibility may be expanding. As the Boston Globe’s liberal editorial page said of the penalties, « That’s tough, but it’s necessary to change the behavior of people who are used to going without insurance, either because they are healthy or are accustomed to relying on the Uncompensated Care Pool to pay for their care. »

‘A stiff requirement’
Smith sounds like he’ll go ahead and sign up.

« I’m required to shell out an additional 6 grand a year now, » he said, guessing at what it might cost him. « I mean — that’s a stiff requirement when you’re only making 30 grand a year or under, you know? »

Out front at Arnold’s, owner Nickerson shows off the new mini-golf course he installed at a cost of nearly $1 million. (« Renting golf balls, » he said with a mixture of disgust and rapture.) While he is glad to offer health insurance and to help pay for it, he said, he doesn’t like the government’s forcing him to do it.

« I think that’s basically how liberal government works — liberals in the government work, » he said. « They force-feed you things that they feel are good for you, like it or not. And that’s the way it is. … There’s so many regulations on every level now, to try to run a business, it’s very, very difficult. Having said that, I’d like to see everyone with health insurance. »

Even employers who already offer insurance will face higher costs under the new law, because more employees will be pressed to sign up for the company health plan. Nickerson said just a little more cost could tip over some small businesses.

« The way I figure my cost is not the cost of the actual item, but what it costs me to keep Arnold’s running year to year, » Nickerson said. « And it’s having less and less to do with the cost of the fish or the cost of the seafood, as it does the cost of insurance and lawyers and taxes. So that’s why the continued push to place more burden on the small-business man is going to eliminate more small businesses, and we are the core of the economy down here. »

Hoping for failure?
The Massachusetts plan is a political experiment, too.

Will the political left accept a reform that leaves insurance companies in the central role, instead of a Canadian-style system run by the government?

Will the political right accept a reform that coerces employees and employers into buying a particular product?

What effect will its success or failure have on reform efforts in other states and in Congress?

And what impact will it have on the 2008 presidential campaign, particularly for Mitt Romney, the former Massachusetts governor who proposed much of the program?

So far, the coalition that birthed the new law is holding: Consumer groups, employer groups and state officials all said that the plan is fair and has a chance to succeed, at least if the growth in health care costs can be stemmed.

« It’s a truly noble experiment, » said Michael J. Widmer, the president of the Massachusetts Taxpayer Foundation, a research group run by employers and associations. « I’m hardly naive, but I have to say the complexity of this as it has unfolded has awed me. I think where we are today is remarkable, given the complexity of all this. »

As for Romney, the taxpayer group has been critical of his claims that he turned around the state’s economy — « there’s been no turnaround, » Widmer said. But on health care, « he and his team were very skillful in how they handled months and months of wrangling. This is the signal achievement of his administration. »

Consumer groups also support the new law, but would like to see the demands on employers greatly increased. They wanted a Canadian-style program but saw that it had no chance here.

« We love single-payer, but it’s not politically viable in this state, » said Lindsey Tucker, health care reform coordinator for the consumer group Health Care for All. « There are too many interests, the government, the providers. That wasn’t an option. This idea of shared responsibility — it’s amazing how well it has worked. It’s very exciting. »

That doesn’t mean the law is without its detractors.

« I would like to say this, » said Jon Kingsdale, a former insurance company executive who is executive director of the state’s new health care agency. « Frankly, there are a lot of people outside of Massachusetts who, I think for ideological reasons, want this to fail. »

« On the far left, there are people who are single-payer enthusiasts. On the far right, there are market enthusiasts. … Nobody in America wants to be told what to do, » Kingsdale said.

« But for the vast majority of people who are already buying health insurance, 90 to 95 percent, they’re going to benefit from having that last 5 or 10 percent to buy in. »

Voir enfin:

France’s model healthcare system
Paul V. Dutton
The Boston Globe
August 11, 2007

Many advocates of a universal healthcare system in the United States look to Canada for their model. While the Canadian healthcare system has much to recommend it, there’s another model that has been too long neglected. That is the healthcare system in France.

Although the French system faces many challenges, the World Health Organization rated it the best in the world in 2001 because of its universal coverage, responsive healthcare providers, patient and provider freedoms, and the health and longevity of the country’s population. The United States ranked 37.

The French system is also not inexpensive. At $3,500 per capita it is one of the most costly in Europe, yet that is still far less than the $6,100 per person in the United States.

An understanding of how France came to its healthcare system would be instructive in any renewed debate in the United States.

That’s because the French share Americans’ distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as « socialized medicine. » Virtually all physicians in France participate in the nation’s public health insurance, Sécurité Sociale.

Their freedoms of diagnosis and therapy are protected in ways that would make their managed-care-controlled US counterparts envious. However, the average American physician earns more than five times the average US wage while the average French physician makes only about two times the average earnings of his or her compatriots. But the lower income of French physicians is allayed by two factors. Practice liability is greatly diminished by a tort-averse legal system, and medical schools, although extremely competitive to enter, are tuition-free. Thus, French physicians enter their careers with little if any debt and pay much lower malpractice insurance premiums.

Nor do France’s doctors face the high nonmedical personnel payroll expenses that burden American physicians. Sécurité Sociale has created a standardized and speedy system for physician billing and patient reimbursement using electronic funds.

It’s not uncommon to visit a French medical office and see no nonmedical personnel. What a concept. No back office army of billing specialists who do daily battle with insurers’ arcane and constantly changing rules of payment.

Moreover, in contrast to Canada and Britain, there are no waiting lists for elective procedures and patients need not seek pre-authorizations. In other words, like in the United States, « rationing » is not a word that leaves the lips of hopeful politicians. How might the French case inform the US debate over healthcare reform?

National health insurance in France stands upon two grand historical bargains — the first with doctors and a second with insurers.

Doctors only agreed to participate in compulsory health insurance if the law protected a patient’s choice of practitioner and guaranteed physicians’ control over medical decision-making. Given their current frustrations, America’s doctors might finally be convinced to throw their support behind universal health insurance if it protected their professional judgment and created a sane system of billing and reimbursement.

French legislators also overcame insurance industry resistance by permitting the nation’s already existing insurers to administer its new healthcare funds. Private health insurers are also central to the system as supplemental insurers who cover patient expenses that are not paid for by Sécurité Sociale. Indeed, nearly 90 percent of the French population possesses such coverage, making France home to a booming private health insurance market.

The French system strongly discourages the kind of experience rating that occurs in the United States, making it more difficult for insurers to deny coverage for preexisting conditions or to those who are not in good health. In fact, in France, the sicker you are, the more coverage, care, and treatment you get. Would American insurance companies cut a comparable deal?

Like all healthcare systems, the French confront ongoing problems. Today French reformers’ number one priority is to move health insurance financing away from payroll and wage levies because they hamper employers’ willingness to hire. Instead, France is turning toward broad taxes on earned and unearned income alike to pay for healthcare.

American advocates of mandates on employers to provide health insurance should take note. The link between employment and health security is a historical artifact whose disadvantages now far outweigh its advantages. Economists estimate that between 25 and 45 percent of the US labor force is now job-locked. That is, employees make career decisions based on their need to maintain affordable health coverage or avoid exclusion based on a preexisting condition.

Perhaps it’s time for us to take a closer look at French ideas about healthcare reform. They could become an import far less « foreign » and « unfriendly » than many here might initially imagine.

Paul V. Dutton is associate professor of history at Northern Arizona University and author of « Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France, » which will be published in September.

One Response to France-Etats-Unis: L’autre chassé croisé des dépenses de santé (Health costs’ triple whammy)

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