mercredi 17 avril 2019
mardi 16 avril 2019
Socialized medicine
Left-wing Democrats in Congress have decided on a new version of “Medicare for All.” Turns out its going to be nothing like the Medicare program seniors are used to. What they have in mind is what we see in Canada.
Everyone (except American Indians and veterans) will be in the same system. Health care will be nominally free. Access to it will be determined by bureaucratic decision making.
Here’s what to expect.
Overproviding to the Healthy, Underproviding to the Sick.The first thing politicians learn about health care is this: most people are healthy. In fact, they are very heathy – spending only a few dollars on medical care in any given year. By contrast, 50% of the health care dollars will be spent on only 5% of the population in a typical year.
Politicians in charge of health care, however, can’t afford to spend half their budget on only 5% of the voters, including those who may be too sick to vote at all. So, there is ever-present pressure to divert spending away from the sick toward the healthy.
In Canada and in Britain, patients see primary care physicians more often than Americans do. In fact, the ease with which relatively healthy people can see doctors is probably what accounts for the popularity of these system in both countries.
But once they get to the doctor’s office British and Canadians patients receive fewer services. For real medical problems, Canadians often go to hospital emergency rooms – where the average wait in Canada is four hours. In Britain, one of every ten emergency room patients leave without ever seeing a doctor.
A study by former Congressional Budget Office director June O’Neill and her husband Dave O’Neill found that:
- The proportion of middle-aged Canadian women who have never had a mammogram is twice the U.S. rate.
- Three times as many Canadian women have never had a pap smear.
- Fewer than 20% of Canadian men have ever been tested for prostate cancer, compared with about 50% of U.S. men.
- Only 10% of adult Canadians have ever had a colonoscopy, compared with 30% of US adults.
These differences in screening may partly explain why the mortality rate in Canada is 25% higher for breast cancer, 18% higher for prostate cancer, and 13% higher for colorectal cancer.
A study by Brookings Institution scholar Henry Aaron and his colleagues found that:
- Britain has only one-fourth as many CT scanners as the U.S. and one-third as many MRI scanners.
- The rate at which the British provide coronary bypass surgery or angioplasty to heart patients is only one-fourth of the U.S. rate, and hip replacements are only two-thirds of the U.S. rate.
- The rate for treating kidney failure (dialysis or transplant) is five times higher in the U.S. for patients age 45 to 84 and nine times higher for patients 85 years of age or older.
We can see the political pressure to provide services to the healthy at the expense of the sick in our own country’s Medicare program. Courtesy of Obamacare, every senior is entitled to a free wellness exam, which most doctors regard as virtually worthless. Yet if elderly patients endure an extended hospital stay, they can face unlimited out-of-pocket costs.
Rationing by Waiting. Although Canada has no limits on how frequently a relatively healthy patient may see a doctor, it imposes strict limits on the purchase of medical technology and on the availability of specialists. Hospitals are subject to global budgets – which limit their spending, regardless of actual health needs.
In addition to having to wait many hours in emergency rooms, Canadians have some of the longest waits in the developed world for care that could cure diseases and save lives. The most recent study by the Fraser Institute finds that
- In 2016, Canadians waited an average of 21.2 weeks between referral from a general practitioner to receipt of treatment by a specialist – the longest wait time in over a quarter of a century of such measurements.
- Patents waited 4.1 weeks for a CT scan, 10.8 weeks for an MRI scan, and 3.9 weeks for an ultrasound.
Similarly, a survey of hospital administrators in 2003 found that:
- 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman.
- 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery.
Jumping the Queue. Aneurin Bevan, father of the British National Health Service, declared, “the essence of a satisfactory health service is that rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged.” Yet, more than thirty years after the NHS was founded an official task force (The Black Report) found little evidence that the creation of the NHS had equalized health care access. Another study (The Acheson Report), fifty years after the NHS founding, concluded that access had become more unequal in the years between the two studies.
In Canada, studies find that the wealthy and powerful have significantly greater access to medical specialists than less-well-connected poor. High-profile patients enjoy more frequent services, shorter waiting times and greater choice of specialists. Moreover, among the nonelderly white population, low-income Canadians are 22% more likely to be in poor health than their U.S. counterparts.
These results should not be surprising. Rationing by waiting is as much an obstacle to care as rationing by price. It seems that the talents and skills that allow people to earn high incomes are similar to the talents and skills that are useful in successfully circumventing bureaucratic waiting lines.
No Exit. The worst features of the U.S. health care system are the way in which impersonal bureaucracies interfere with the doctor-patient relationship. Those are also the worst features of Canadian medical care. In Canada, when patients see a doctor the visit is free. In the U.S., the visit is almost free – with patients paying only 10 cents out of pocket for every dollar they spend, on average. In both countries, people primarily pay for care with time, not with money. The two systems are far more similar than they are different.
In Britain, private sector medicine allows patients to obtain care they are supposed to get for free from government. Middle and upper-middle income employees frequently have private health insurance, obtained through an employer. A much larger number of Britons use private doctors from time to time. The rule seems to be, “If your condition is serious, go private.”
Canada, by contrast, has basically outlawed private sector medical services that are theoretically provided by the government. If doctors, patients and entrepreneurs think of better ways of meeting patient needs they have no way of acting on those thoughts.
This is where the U.S. system is so much better—even though, as in the Canadian system, U.S. Medicare pays doctors the same way it did in the last century, before there were iPhones and email messages. Many U.S. employer plans are just as bad.
But because U.S. employers are free to meet the needs of their employees rather than live under the dictates of a politically pressured bureaucracy, one of the fastest growing employee benefits is concierge care. For as little as $50 a month for a young adult, patients can have 24/7 access to a doctor by phone and email and all the normal services that primary care physicians provide.
Uber-type house calls, consultations by phone, email and Skype, cellphone apps that allow people to manage their own care and other innovations in telemedicine are taking some parts of the private sector by storm.
These are the kinds of innovations that would be outlawed if the congressional Democrats have their way.
JC Goodman
For more on these and other issues, interested readers may want to consult my congressional testimony, delivered with Linda Gorman, Devon Herrick and Robert Sade.
lundi 15 avril 2019
La France des mensonges: l'incroyable croissance du nombre de fonctionnaires: Hollande et Macron
Effectifs de la fonction publique depuis 2011 (Source : INSEE – EA = Emplois aidés)
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| Le manque de moyens! |
Claire Etcherelli, Simone de Beauvoir l'illusion de devenir et la réalité d'être
Niall Ferguson
Fantastic Sunday Times piece on the new totalitarianism by Niall Ferguson.
A new red army is out to silence debate. We must rise up and resist it
by Niall Ferguson
14 April 2019, 12:01am
14 April 2019, 12:01am
Seventy years ago this month Nato was established to protect western Europe and the freedoms of its inhabitants from the threat of Soviet communism. It has become clear to me that we now need a similar organisation to protect western intellectuals from a growing threat to academic freedom.
The North Atlantic Treaty, signed by 12 governments in Washington on April 4, 1949, was a treaty of mutual defence “to safeguard the freedom, common heritage and civilisation of their peoples, founded on the principles of democracy, individual liberty and the rule of law”. Article 5 of the treaty states that “an armed attack against one or more of [the signatories] . . . shall be considered an attack against them all”.
It would be an oversimplification to say that this alone deterred the Soviet Union from attempting to extend its power any further west than the River Elbe. Nevertheless, the commitment of successive American presidents to Nato, along with the presence of US troops and missiles in western Europe, may be said to have worked. During the Cold War, Moscow sought to expand its influence in Latin America, the Middle East, east Asia and Africa. It left western Europe alone.
In those days a small but courageous group of western academics did what they could to expose the wickedness of communism and to support political and religious dissidents in the Soviet sphere of influence. A member of that group was Roger Scruton. During the 1980s he travelled to communist-controlled Czechoslovakia to assist an underground education network run by the Czech dissident Julius Tomin. In 1985, during a trip to Brno, Scruton was arrested and expelled.
A philosopher of international renown, a prolific author, a composer and a polymath, Scruton has one of the most powerful minds I have encountered. But he is one of those rare thinkers who seek to change the world as well as to understand and explain it. There was a time when those qualities were venerated. In 1998 he was awarded the Czech Republic’s Medal of Merit by its then president Vaclav Havel, himself a former dissident. A knighthood came in 2016. And last year he was appointed chairman of the government’s commission on buildings.
Almost immediately after that, however, the attacks from the left began. The campaign against him culminated last week in the publication of a cynical hit-piece in the New Statesman, which misrepresented his views on a number of issues — the influence of George Soros, China’s policies of social control and the origins of the term “Islamophobia” — in order to portray him as a racist. The government took the bait. James Brokenshire, the secretary of state for housing, immediately sacked him. A spokeswoman for the prime minister described his comments as “deeply offensive and completely unacceptable”.
In reality, Scruton had been framed. The author of the New Statesman hatchet job, George Eaton, had edited quotations and inserted his own commentary with the clear intention of getting him sacked. He further massaged the “gotcha” quotes (“outrageous remarks”) on social media. Having achieved his objective, Eaton jubilantly published a photograph — later deleted — of himself drinking champagne from a bottle with the tagline: “The feeling when you get right-wing racist and homophobe Roger Scruton sacked as a Tory government adviser.”
A month rarely passes without some such tale of a conservative academic being “taken down”. In March it was the turn of the Canadian psychologist Jordan Peterson, who was informed by Cambridge that the visiting fellowship he had been offered by the faculty of divinity was being cancelled. The reason? At a book signing he had been photographed standing next to a man with a T-shirt bearing the (obviously facetious) slogan “I’m a proud Islamophobe”.
Before that it was the US political scientist Samuel Abrams, who now faces a “tenure review” at Sarah Lawrence College in New York. His thoughtcrime? An article pointing out that academic administrators are even more left-leaning than professors.
January’s cause célèbre was that of Peter Boghossian, a philosopher at Portland State University, who is being investigated by his own institution. Why? Because he was one of the perpetrators of the brilliant “grievance studies” hoax, which exposed the ease with which supposedly scholarly journals could be duped into publishing bogus articles.
Then there’s Roland Fryer, the Harvard economist who has been suspended for more than a year because of highly questionable allegations of sexual harassment. I have a hunch those allegations might never have been made if Fryer, an African-American, had not published a paper concluding that the police did not, after all, use lethal violence more readily against black suspects than white.
And let’s not forget Professors Nigel Biggar and Bruce Gilley, both denounced last year for daring to point out that not every aspect of the history of the British Empire was a crime against humanity. I could go on, but you get the picture.
In every case, the pattern is the same. An academic deemed to be conservative gets “called out” by a leftist group or rag. The Twitter mob piles in. Mindless mainstream media outlets amplify the story. The relevant authorities capitulate.
The most striking common feature is the near-complete isolation of the target. Did Abrams’s colleagues step up to defend his (and their own) academic freedom? On the contrary: 40 of his fellow professors endorsed the student leftists’ demand that his tenure be reviewed. Did Fryer’s fellow Harvard economists question the way their only black colleague was being treated? Not one has publicly defended him.
My message to all professional thinkers — academics, public intellectuals, writers of any stripe — is this: we either hang together or we hang separately. Even being an avowed progressive won’t help you if you fail just one weakness test, as Bret Weinstein did when he objected to the idea of a “day of absence” for all white students and faculty at Evergreen State College in Washington state.
A direct descendant of the illiberal, egalitarian ideology that once suppressed free speech in eastern Europe is now shutting down debate in the West. For those, like Scruton, who once helped Czech dissidents to get degrees in theology from Cambridge, the irony is bitter indeed.
The lesson of the Cold War is clear. From now on an attack on one of us must be considered an attack on all of us. I, therefore, invite all who believe in the fundamental human freedoms to sign a new Non-conformist Academic Treaty.
The present danger to free thought and speech is not Red Army tanks pouring through the Fulda Gap in Germany; it is the red army of mediocrities waging war on dissent within academia and the media. It is time to confront these people with the one thing that will deter them, as it once deterred the Soviets: massive retaliation.
Divided we shall fall. But united we can ensure that the reputation destroyed last week was not Sir Roger Scruton’s but the New Statesman’s.
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