services that offer more marginal benefit
may still purchase it if they are willing to pay
without a proportionate marginal cost.
for it themselves. The same is true for technol-
Translated into English, you eat more at
ogy. Likewise, patients may ignore the "coordi-
a buffet because the refills are free, and
nated care pathway" and accept higher prices,
you use more health care because insur-
paying more for immediate access.
ers generally make you pay up front in
In addition, the added resources from
premiums, rather than at the point of
payments by private insurance have
care. The obvious solution is to shift
increased the supply of health care technolo-
more of the cost away from premiums
gy and services. By increasing the overall
and into co-pays or deductibles, thus
amount of capital available for investment
increasing the sensitivity of consumers
above and beyond the restrictions imposed
to the real cost of each unit of care they
by the government system, private insurance
purchase.82
payments increase the number of hospital
beds and the amount of technology available
within the system. The capital infused
However, the benefits of private insurance
through private insurance may also increase
are not equally distributed. The wealthy are
the number and training of physicians.80
more likely to be able to pay privately to escape
The new French
the government system, creating in essence a
In essence, the French system avoids wide-
government
two-tier system. That has resulted in a dispari-
spread rationing because, unlike true single-
ty in health outcomes based on income.84
payer systems, it employs market forces. Even
has made a
the OECD says that the "proportion of the
While this is certainly the case in the United
crackdown on
population with private health insurance"
States and elsewhere--and there is nothing
health care
and the degree of cost sharing are key deter-
wrong with the wealthy being able to pay more
minants of how severe waiting lists will be:
to receive better care--it demonstrates that the
spending one
professed goal of entirely equal access is largely
of its top
Waiting lists for elective surgery general-
unattainable even under this government-run
ly tend to be found in countries which
health system.
priorities.
combine public health insurance (with
A 2004 poll showed that the French had the
zero or low patient cost sharing) and
highest level of satisfaction with their health
constraints on surgical capacity. Public
care system among all European countries.
health insurance removes from patients
This is partly because their hybrid system has
the financial barriers to access leading to
avoided many of the biggest problems of other
high potential demand. Constraints on
national health care systems. Yet it also stems
capacity . . . prevent supply from match-
from French social character. For example, by a
ing this demand. Under such circum-
three-to-one margin, the French believe the
stances, non-price rationing, in the form
quality of care they receive is less important
of waiting lists, takes over from price
than everyone having equal access to that
care.85 This means the French experience may
rationing as a means of equilibrating
supply and demand.81
not be easily transferable to the United States,
which has a far less egalitarian ethic.
While satisfied with their care today, the
And Ezra Klein praises the French because
French do express concern about the future.
In particular, they acknowledge the need for
[France's ability to hold down health
greater cost control. This leads to the stan-
care costs] is abetted by the French sys-
dard contradiction inherent in government
tem's innovative response to one of the
services: most people are opposed to paying
trickier problems bedeviling health-poli-
more (either through higher taxes or out of
cy experts: an economic concept called
pocket), yet they worry that cost-control
"moral hazard." Moral hazard describes
measures will lead to a deterioration of care
people's tendency to overuse goods or
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