Two Cents on Health Care

By Kelly Jean Cogswell

When I drop in on the American health care debate my only response is "Freaks!" Seriously. Universal health care = death panels? Communism? Armageddon? On the other hand, who on earth believes access and regulation will fix it all?

I'm an unexpected skeptic. I'm living in France where the value of universal coverage is self-evident. Despite their complaints about the high cost of care, middle-class French people pay very little, poor people pay nothing, and even outsiders like me benefit from government regulation, subsidies, and a system among the best in the world.

To give you an idea of what it means in financial terms, last year I had an ovarian cyst that involved a lot of doctor visits and eventually surgery. I paid full price for everything before my insurance returned the bulk of it. Sixty euros ($86) covered one visit to a private gynecologist, 28 euros for a visit to a public clinic. A sonogram was eighty euros. An MRI ran 454 euros. Surgery with three whole nights in the hospital was 4450 euros ($6367) including hospital bed, surgeons' fees, anesthesiologist, medication, bed pan, coffee and croissants. And I waited less than a month for this non-emergency surgery to be scheduled.

The most important thing, though, is that at every stage the care was competent and professional. Hell, it was the best I've ever had. Unsurprisingly, the World Health Organization as well as the Commonwealth Fund rank France, along with Switzerland, Britain, Canada, and Japan, as having the best health care system in the world, not just in access, but in having the best outcomes in all age categories for cancer, heart disease, diabetes, and rates of other chronic diseases.

For me the question is, even if the flying pig of universal health coverage manages to get past the increasingly powerful lobbyists and their congressional lackeys to give every American insurance, can the United States actually transform its medical culture enough to make universal health care work? Access aside, America's existing health care system stinks. You can pay a lot, or pay a little, you're still in a country rated a pathetic 37th on results.

My theory is that the key to the success of French medical care is not just access, but access to one standard of care for everyone, not just in terms of how medical recommendations are made, but in terms of class.

I'd heard about it from one of my old neighbors, a medical social worker, who told me how he might spend a morning in a total slum with a recent hospital discharge, and the afternoon visiting a patient whose possible inheritors were squabbling in an adjoining room.

I got a chance to watch it myself last year. In the waiting room at the public hospital, there'd be a student, a middle-class matron, an au pair. The secretaries terrified rich and poor alike with the same French bureaucratic chill. The doctors greeted everyone with the same face of professional interest, the same polite handshake.

Compare that mix of patients and the imposition of the same social conventions to New York, where there's clearly a two-tier system of health. The poor are treated by specialists in the poor, who rarely leave their medical ghettoes to treat the rich. In public clinics, nurses snicker at patients to their faces, make fun of accents even if they have one themselves. Doctors, usually paid less than their peers in private practice, assume that the financial poverty includes moral and intellectual lack, too, and treat you accordingly.

Which is not to say they don't prescribe the expensive procedures and tests. The problem is the staff just don't take the same care with some poor schmuck as they would with the rich.

There was the time I was on Medicaid and having intestinal problems. They recommended a colonoscopy and I was right in the middle when the anesthesia wore off. They couldn't give me more because my blood pressure dropped, which they hadn't prepared for though apparently it's a common side-effect, and despite the fact I was begging them to stop, these medical professionals just went straight on like I wasn't there begging them to please, oh my god, please stop.

No, access isn't everything. I could tell you a dozen stories like that. Only a few of them mine. Should I be happy more people get access to that?

I think this two-tier system is also bad for the middle-class or rich. Aware of the differences in pocket books, the potential for patient lawsuits as much as the payoffs in lucrative tests and prescriptions, I doubt doctors give them the objective, thoughtful care they should. They don't refuse to offer useless treatments, don't take chances when they ought to.

Reform? Hell. Better burn down the house.