Your Country Would Like to Treat You to a Doctor’s Appointment

The financial crisis is getting all the headlines and, so it is claimed, occupying all the attention of at least one presidential candidate.

Yet a bigger economic issue is hardly being addressed: the exploding costs of health care in the U.S., where we spend a far greater share of our incomes on health than people in other rich countries. How do other countries avoid having health care attract an ever-growing share of resources under their systems of universal coverage and still produce health outcomes at least as good as ours?

One way was made clear yesterday, when, as a (temporary) citizen of Bonn, Germany, my wife received a letter saying she had been scheduled for a free mammogram at a particular time and place. With a preset appointment, no effort is required to arrange things; this arrangement would certainly not exist for most people at home.

Substituting the small cost of preventive care for the large costs of curative care for all citizens seems like a sensible way to contain medical costs under a universal health care system.

Maybe, as I think will happen, the U.S. will finally provide access to health care for all citizens; and it may be possible to do so without shifting still more resources into this sector.

David F

Regarding reducing smoking rates, NY Mayor Bloomberg and Health Commissioner Frieden already have a very successful strategy that reduces smoking: the smoking rate among teens is 8.5% vs. 23% nationwide. They got 200,000 adults to quit smoking in the last few years. This they did by banning smoking in public places and bars, raising the price of cigarettes to $10/pack (which also makes it harder for teens to afford them), sending teens into stores to try to buy cigarettes and if successful the stores are fined, a massive anti-smoking TV campaign, and periodic offers of free nicotine replacement patches. This is a simple program that should be replicated nationally -- but we lack the political will.

Jane Gray

@29 I agree that the people who have risky behaviors are the largest liability to any socialization of medicine plan.

Specifically the obese and smokers. Testing for obesity is pretty basic (I'd say draw the line at 250 pounds for women and 300 for men. At that point no one except maybe a professional football player could argue "its mostly muscle")

Smokers are trickier. The only real way I can see to lessen their effect would be a an ever growing tax. Say 5% larger every year, dollars that would directly go into medicaid (or whatever you call your program). Smokers are disproportionately poorer than average, after 10 years (or 20) a majority might find themselves priced out of the market. And surely an appreciable chunk of change per pack of cigarettes (eventually $10, say) would go a long way towards offsetting the public cost.

@16 Their doctors reminding them to diet and exercise doesn't do a thing. We live in a country where people do what they want to their bodies and deal with the consequences later. These risky behaviors will tie into disproportionate costs to any socialized medicine.




Had you lived in Canada, England, Etc. you would have had to wait much longer for the MRI. Had the MRI's results indicated that your son had to have surgery on his knee, it would have been classified "elective surgery" and your family would have to wait at least year for the operation.

In this light, your ordeal (although it still sucked) appears much more tolerable. In terms of actual monetary costs, it is much more expensive here. In terms of all the type of economic costs (the expense of waiting, etc.) you got a good deal.


i always thought you americans were crazy with your healthcare system (or lack thereof)

it costs you a fortune, you get worse health outcomes, and the people at the bottom of the heap miss out completely - it's pretty much the worst of all possible situations

David F

I am MD who frequently travels to Israel. I recommend people consider medical tourism as a well to reduce health care costs.

Even though prostrate cancer is a slow growing cancer only about 50% survive in France and Germany and less than 50% in the UK vs. 80% in the US.

Much has been written in the press about "Moral Hazard" that is, subsidizing Wall Street for their risky behavior with taxpayer dollars. It doesn't seem fair that firms that were doing things risky financially should be rescued by the tax payer. Yet, many who want socialized medicine in fact propose doing just that. Cigarette smoking costs 12% of health care costs (it contributes to Alzheimer's Disease and many other chronic long term health problems) which comes to $250 billion per year or $13 per pack. Yet we don't require smokers to pay for their habit which since 1964 -- 48 years ago -- people knew was bad for them. Non-smokers are subsidizing the smokers unhealthy lifestyle. You want to reduce health care costs and take care of the uninsured? Start making those people who knowingly participate in risky behavior pay for that behavior, unsubsidized by those that choose to live a healthy lifestyle.



Delays for some procedures are indeed much longer in Canada - normally, but not exclusively, for procedures where the delay has a low impact on the outcome. On the other hand, in the US, 22% of those surveyed with income between $25000 & $50000 reported "postponing care". These are delays that don't show up in waiting lists.

However, to take it out of the anecdotal, and into the stats (or group anecdotal), satisfaction surveys do exist. To use the first one I found, the Commonwealth Fund survey (2007):

Of Australia, Canada, Germany, the Netherlands, New Zealand, the UK, and the USA, the US respondents were most likely to say the health care system needed to be completely rebuild (34%, Canada was 12%), and least likely to say it worked pretty well (16%, Canada was 26%). It's interesting to see how satisfied the Dutch are, clearly the happiest... while Germany was 2nd worst (after the States) in satisfaction.

And of course, comparisons of health care outcomes exist, where the US does consistently poorly (compared to the usual industrialized suspects) on life expectancy, infant mortality, youth mortality (even after correcting for higher murder rate in the US)...

There's no question that the US does subsidize world health care through "first-adopter" driving of innovation. Even ignoring the higher cost of the US system, however, it leads to poor health & satisfaction outcomes.



#24- Thank you. In the US, focus on those that are UNinsured. Don't blow up the whole thing.
Get the data on who, why, where and when.
Maybe they do NOT want health care.
Been denied. Just lost a job etc.

I say find a way to cover every child under 4 for individual making less than 25k and couples making less than 50.
Keep promoting the Health Savings Accounts.


@16: Preventative care is only more effective when those who are at risk are the ones receiving that care. If a woman had no history of breast cancer (nor the genes responsible for higher breast cancer rates) and is at little risk, it is not cost effective for her to receive a mammogram. I am not sure how to tell someone that they cannot enjoy the free healthcare that they have access to and have subsidized.

Also, what is the problem with expensive healthcare? That money simply flows back into our own GDP. We are not (yet) outsourcing our medical care.


#16. I have. It's not. Or, more accurately, that's a gross generalization that is not well supported by the data. Some prevention is very cost-effective. Some is not.


@18--under universal healthcare (note: this is not necessarily "governmental run" or "socialized"), you would not get an additional 270 million insureds. Today the system, such as it is, covers all but 45 million or so individuals. Those would be the ones that would be pulled into a universal system. And do not underestimate the current cost of your subsidization of them--about $992 of the cost of your coverage is this current subsidy. If we could reallocate that rationally, as opposed to spending it late in an illness in an ER, we would be far better off.


Jim F #15 Another reason medical costs are lower in Europe is that health care providers (doctors and nurses) are paid much less than in the U.S.

Our NHS general practitioners get the equivalent of $250.000 for a 5 day week regardless of the number of consultations they give and senior nurses round about $65,000.
But our docs like yours look as if they're sucking a lemon when a patient is 'too' informed about a treatment or a prescription.

Olivier Lacan

Sorry to point out the naiveté of this post, but the evidence presented is higly annectodal, as it was pointed out a free mamography is not free, you pay for it either with increased direct taxes or indirect ones (I live in France, I should know).

I don't have statistics on the delay for doctor's appointments in Canada and the only thing I have for France are annecdotal stories as well, but I can say with some degreee of confidence that any Canadian considers the waiting times for actual medical practices (specialists especially) incredibly long (I've heard the 6-month at least quite often). And despite the fact that Paris is well treated, I fear that most patients in smaller cities in France are treated with similar delays.

No investment rewards perhaps, prices are capped for most doctors ("conventionned" ones which probably get benefits from it), there's isn't enough med schools for the amount of students interested in the field (stories of students fighting to get seats in amphitheaters abound). Competition among students isnt't the problem, it's just that there isn't enough available spots for them.

Anyway, let's not oversimplify the healthcare debate, it's not a good idea for either side of the argument.



Spiraling costs is an unintended consequence of tax breaks for health care.

-The tax breaks for insurance lead to more money for health care being paid upfront in the form of higher insurance premiums.
-Higher premiums lead to low copayments.
-Low copayments lead to lowered price elasticity of demand for patients.
-Lowered price elasticity of demand leads to overuse and high prices of care.
-The costs of overuse gets charged back to the insurance pools in the form of higher premiums.
-The cycle repeats itself.


Is it just me or are Mr. Hamermesh's posts becoming extremely tiresome? Oh, if only we could be like the enlightened Europeans - everything is so wonderful here - the US is such a bad, bad place. Let's start hearing about the economic issues in Germany associated with the high unemployment, the high percentage of children on welfare, political extremism, immigration, an aging population, etc.


I'm sorry I don't have time to dig up the source (the topic was probably discussed on EconoLog:, but preventive care is *more* expensive than curative care – you need to check many, many women for breast cancer to catch one case early. It may be a good thing to do (it certainly is for the patient whose cancer is detected early), but it certainly is not cheaper.


As several posters have pointed out the correlation is questionable. Another reason medical costs are lower in Europe is that health care providers (doctors and nurses) are paid much less than in the U.S.

With the knowledge that a singular experience can be misleading here is one personal experience: A speaker at one of my conferences cut a vein in his leg minutes before he was supposed to do the opening keynote. We rushed him by ambulance to a Berlin hospital. After being initially apprehensive, he came back happy: He got in immediately, the total experience cost him only US$80, he didn't have to figure out how to make an insurance claim with Blue Shield from Berlin, and seemed fine.

Then on the long flight back to New York, the stitches in his leg popped.

Sometimes you do get what you paid for. Or less.


Are we counting the additional tax dollars paid towards the cost of the free mammogram?

How about is health care remained completely private but was regulated with a classification system? A "certified" provider's plan includes all those free preventative tests at the base cost while non-certified plans can provide as little coverage as the participant would like to pay for.


I was just complaining about this subject this week!! My teen-aged son injured his knee last week. We took him to the emergency room due to it being 8:00 at night. They did an examination, took x-rays, and determined he needed an MRI. Instructed us to follow up with an orthopedic surgeon.

We contacted the surgeon the next day. They couldn't get him in until the following Tuesday. The surgeon's office instructs us to have all of his records faxed to their office.

We go in on Tuesday. The receptionist is very happy to hear that we have BC/BS because we do not have to get approval for any of the procedures.

The doctor is an hour late for the appointment. He spends 5 minutes with our son to tell us he needs an MRI. I asked him why he needed to examine our son and tell us the exact same thing we found out at the ER. He didn't have an answer for us.

He then instructed us that we can have the MRI done here in town, but there is a 10 day wait to get it done. He also informs us that we can get it done this week at an out-of town-clinic. Doing some research we find out that the out-of-town clinic costs half the amount for the same test because they do a larger volume. The local MRI is the only one around for 75 miles so they can charge what they want.

We get the MRI done, but the doctor would not tell us the results of it unless we came into the office for another visit!!! My husband threw enough of a fit that they reviewed the MRI and let us know there was no other damage. They indicated they still wanted us to come in for an appointment so they could set us up for physical therapy. I told them no thanks, contacted a physical therapist and made the arrangements myself.

People wonder why it costs so much for heath coverage.


James A

That's great that they schedule preventative care, but what about the actual treatment if they find something? Based on my conversations with friends in Canada, they'll schedule that too, but it usually is months out, if ever. So I guess they can find that cancer, but good luck in getting in to get it treated.


All British women are offered free scheduled annnual cervical smears and all women over 45 have free scheduled mammograms 3 yearly. The government has just announced that from next year all British residents of 40+ will be offered a free annual comprehensive health checkup, including blood tests and X rays etc where advisable.
We in the UK often complain about our national health service but compared to some countries we have a lot to be thankful for.