Tuesday, September 25, 2007

The Slippery Slope Argument

My dialogue with Anonymous in the comments to this post suggests that the government has failed to get across a couple of key points about the new copayments for medication and other services. To reiterate, the poorest of the French (some 15 million people) are exempt from the copays, and the total additional copay per person per annum is capped at 50 euros (for details, see here).

This is a relatively modest burden to place on the remainder of the population, and it only begins to reduce the large and growing social security deficit. So why the outcry? One argument that is often heard is of the "slippery slope" variety: the reform is but a first step toward a more "individualized" or "Anglo-Saxon" model of health care, in which it's every man/woman for himself/herself, with no collective responsibility. This argument seems to me to caricature both the reform and the "Anglo-Saxon model," which is not "individual" but mutualized through private insurance; and note, too, that the French system of mutualization through the state is supplemented by private mutuelles as well. Mutualization through the state that is not fully funded, as in the French case, makes the actual incidence of the burden of health care costs difficult to locate. The cost is borne partly by employers, partly by workers, partly by consumers, and partly by taxpayers in general who must service the debt.

It is easy to imagine a similar reform in copays being carried out by a Socialist president. The name of the payment would most likely be different: instead of franchise médicale we might have contribution à la santé collective généralisée. So, again, the question is, why the outcry? Is there any reason to believe that Sarkozy is out to dismantle the social security system? None that I can see. The opposition speaks vaguely of "other ways of financing the social security deficit," but the choice between an actual policy and an unspecified but allegedly better one is always easy for the hopeful and gullible. The debate, then, is not about the particulars of policy but about trust. The outcry expresses the distrust that Sarkozy inspires in a good many people. But distrust is an emotion, not a political program or even an effective critique.

For additional information about French consumption of prescription drugs relative to other European countries, see here. (Thanks once again to Éloi Laurent for the pointer.)


Anonymous said...

Is it the government who's not made the details clear, or the media? I only saw the points you made about exemptions and caps this morning in Libération; on the TV, they didn't mention them at all. This said, I do recall about a year ago, when this idea was raised, that a cap had been mentioned.

But I think the broader issue is that the French - or anyone who's not French and who lives in France, like me - are used to "temporary" taxes becoming permanent. Look at the CSG and the RDS; both meant to be short-term stopgaps that have now become fixtures of the tax system. Also, they allow the goverment to "lower taxes", without really lowering them, since everyone pays the CSG, but only those who earn enough to pay income tax benefit from reductions.

Unknown said...

I agree that the media could do a far better job than they do. Since starting this blog, I have frequently had occasion to gnash my teeth over the fact that Le Monde falls so far short of the mark as the newspaper of record. I frequently have to do research about details that would not be necessary if Le Monde came even close to the level of coverage of the NY Times, which is far from perfect. Still, that said, the details in question were mentioned in yesterday's Figaro and today's Libé, as well as in the Tribune and probably in other media as well (I don't read quite everything, but almost). I think readers have to take some responsibility as well. There is a tendency to skip over details, especially where there is an assumption that the government is up to no good.

As for continuing temporary taxes, yes, of course, you're right, but I don't think anyone has tried to sell this as a temporary tax. I think copays are intended, by this government at least, to become a permanent feature of the system. Indeed, they will probably increase in the future--and perhaps that's what you're getting at when you suggest that there is a certain effort to disguise the ultimate goal of the reform. But copays serve another function in addition to raising revenue: they discourage abuse, and in order to do that, they have to rise to a level that imposes at least some hesitation in the consumer. One can challenge this way of regulating drug consumption, which many agree is excessive in France; it might be preferable to offer incentives to doctors to prescribe less, but such a policy has its own drawbacks (it is one of the complaints against managed care in the US that medical decisions are biased by cost considerations). Nevertheless, there can be no progress unless the problem is recognized.

Anonymous said...

Since we have been covered by French Secu, I've been amazed by the amount of drugs prescribed by our doctor that are fully covered. What amazes me still more is that Secu is still covering many "naturopathic" remedies and other drugs whose efficacity has not been proven. There seems to me every reason to tighten up on this, or at least to ask people who want to take infinitesmal doses of arsenic to pay for them themselves.

Regarding increased co-payments for physicians' services, I'm not sure whether that is a slippery slope of not. I can only say that to an American, the slope seems very long. Where in the US can you see a GP for under $30 or a specialist for under $50--and then have most of that reimbursed?

dominic said...

The "trou de la secu" is a myth!There will be no deficit when all the big companies will have paid what they own!That's there duty to pay!Its the duty of the governement to ask for it!Patients have not to pay that and we medecins are suposed to do medicine and not counts!Bashing doctors or patient is a poor political reflexion.As yours.