Is US Healthcare Genuinely Capitalist?

Framing the question about US healthcare as socialist vs capitalist is dishonest, unhelpful, and unfair.

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I haven’t been writing much because I’ve been doing a great deal of research about psychology and, specifically the work of Amos Tversky, Daniel Kahneman, Cass Sunstein, and Dan Ariely. One reason I’ve been reading so much is my back went out leaving me to lay around more than I normally would healing. Besides giving me more reading time than usual, that also opened an opportunity to think about the US healthcare system and what these psychologists can tell us about perceptions.

There’s a pernicious message, a widespread perception, that the choice for reforming the US health system to lower cost is between capitalism and socialism. I’ve come to realize that perception, like many perceptions, is simply untrue. There are healthcare systems that provide universal care while simultaneously embracing the benefits that capitalism provides.

Two of the concepts I’ve been studying involve framing and anchoring. They’re simple but powerful concepts to understand. Vastly simplified, framing refers to the insight that people tend to react based on how something is presented. Anchoring is the concept that people tend to judge something based on an initial thing, an anchor. I believe both these concepts are important to understand when thinking about healthcare in the US. Pointing out the obvious, these lessons apply far more widely than healthcare.

Some background: for those who don’t know, I’m American but live and work in France, at INSEAD. When I was living in the US, I had both employer-provided health insurance and also purchased private plans, both before and after Obamacare. My insurance is provided, like everybody else legally working in France, by the government. Like the vast majority of French, I also have a private supplemental policy.

I’ve come to realize that Americans have an enormous misunderstanding of European healthcare systems. Most Americans believe that, for better or worse, US healthcare is a capitalist system and the French system is socialist. I know both systems and believe that is exactly backward. That is, the US system was framed and anchored as capitalist and the European systems, including France, as socialist. The perception that the US is capitalist and France is socialist is simply taken for granted. Like many perceptions, I believe it’s also incorrect and, especially in the context of healthcare, harmful to both the physical, mental, and economic health of the US.

Let’s check out how the French system works. Everybody is covered under social security. It’s similar to US social security. US social security costs 15 percent of pay up to $142,800 (in 2021) plus 2.9 percent for Medicare, uncapped: a total of 17.9 percent. In France, social security taxes are 20% of pay with no caps. For those earning less than $142,800, the cost of the French system is 2.1 percent more expensive.

What does that 2.1% buy? There’s core health insurance that covers everybody, short and long-term disability, some life insurance, and retirement benefits more generous than the US system.

It’s about this time that somebody will jump in to argue wait times for doctors must be terrible, the quality of care awful, the medicines similar to medieval potions, and the entire system staffed with faceless uncaring bureaucrats. That description is not only wrong for France but — when we think about it — is actually closer to how the US system works.

Don’t take my word for it about French wait times: fire up Google Translate, go to doctolib.fr, and search. You’ll see there are plenty of openings at reasonable times with all the same specialists the US has. If you have a more pressing need, your general practitioner will almost always see you the same day or refer you to somebody else who will. You can also show up to the emergency room which will have a longer wait time — more comparable to the US emergency departments — though with vastly lower cost. Some doctors will come to your house though they charge more; when my back went out I had a house call that cost €55 that was covered entirely by insurance.

Click through on doctolib and you’ll also see prices because virtually all medical providers have entirely private practices and set their own prices. The base price for a GP visit is €25 and there are lots of doctors who charge that. However, there’s nothing stopping doctors from charging more and there are plenty who do just that, especially in Paris. My first doctor, who since retired, charged €35 per visit. Most but not all hospitals are run by the government but this isn’t especially different than the US where emergency departments are required to take anybody who walks in. Except, of course, the patients in France are actually cared for and the hospital reimbursed at reasonable rates whereas the US is known to dump them outside in the middle of the night.

This brings me to the next part where the French system is more capitalist than socialist: there is an active and competitive market for supplemental insurance that covers co-pays and those doctors and clinics that charge more. Google “acheter mutuelle france” and you’ll see lots of listings, including the obligatory wall of paid ads, for the “mutuelle” private supplemental policies.

My employer provides one though there are even mutuelle’s that provide double supplemental insurance for those who, for example, don’t want any co-pays if they need excessive dental work. The market for health insurance in France is large, thriving, competitive, and private.

One benefit of my mutuelle is that prescriptions are covered 100%. Despite that insurance pays, pharmacies tell you the price and I have one prescription that costs €34. The lowest price for the same prescription in the US — same dose, same brand, same everything — costs just over 9x as much.

When the government bargains in bulk to set prices, those prices are far lower which is exactly the case with any bulk buyer. Preventing a large buyer like Medicare from negotiating prices as the US does is not capitalist by any stretch; it’s some type of mutated socialism for businesses. By the way - those prices aren’t tied to social security. If you’re on vacation in France and need a refill, find a doctor to translate your prescription then walk into any pharmacy and, even as a tourist, you’ll pay the negotiated price.

What about the argument that pharma companies need the funds for R&D? It’s bunk: they consistently spend more on stock buybacks than R&D (yes, that’s my photo in the story). Look how fast Pfizer and Bio-N-Tech produced an affordable effective COVID vaccine they sell at a reasonable price. This is a great example of how the system could and should work when these businesses focus on medicine instead of markets and marketing.

I’ve been asked if this is like Medicare for All. The answer is … not really. Medicare Advantage, with the supplemental policies, is a similar system except there is no option in France for coverage that doesn’t allow doctor visits, cover medications, and the mutuelle supplemental policies are far less expensive. My parents are on Medicare and told me they pay about $500 per month give or take. A top-tier mutuelle with no co-pays for an older couple would be far less expensive.

One important element the French system eliminates is administrative overhead (yes France, of all places, has less administration for healthcare than the US). Everybody has a green social security card that ties to your mutuelle and bank. Most doctors visits are paid for by patients out of pocket but, with a swipe of the magic green card, funds are reimbursed in a bank account within a week from both social security and the mutuelle. That same green card reader exists in every clinic and pharmacy.

Many doctors don’t have receptionists much less billing clerks; they’re not needed. A shared phone and online scheduling service like doctolib take care of their administrative needs. The state even provides a healthcare records system for free to medical providers.

Are physicians paid less? I’ve done some back-of-the-envelope calculations and don’t think so after expenses are taken into account. Without all the overhead including bickering with insurance companies and massive malpractice policies, they’re able to see more patients. I’m not sure they make as much as US physicians but they’re very well compensated and spend the vast majority of their time practicing medicine, not doing a payment tango with various insurers. Plus, medical school is free so they don’t carry the burden of student loans. Ironically, one reason malpractice insurance costs far less is that if a patient is injured their lifelong care will be taken care of by social security so there’s no need for enormous compensatory damages to pay medical costs for life.

I don’t see that the US health system is capitalist. There’s a lack of competition, enormous centralized decision-making, inadequate price transparency, massive government regulatory support for the status quo, illegal collusion, and, until recently, even legal price collusion. Patients have little to no bargaining power and are at the mercy of a bureaucracy. Don’t like it? Pound dust and die, comrade. That sounds more like a system Karl Marx would design, not Adam Smith.

The French system, in contrast, sounds a whole more capitalistic. Healthcare providers compete for patients by offering different prices, hours, and attitudes towards the practice of medicine. Thanks in large part to genuine capitalism, the French provide better care at a far lower cost.

All this leads to the question of why Americans believe the French system is more socialistic. Even those who support radical reform buy into the perception that European countries like France, which isn’t atypical, are socialist and the US is capitalist. I’d argue it’s long past time to rationally think through and correct that perception. I strongly believe that capitalism, like the French health care system, works well. Soviet-style communism — with the faceless bureaucracies making decisions from afar — doesn’t. Yet that’s exactly what’s going on with US healthcare.

Find the Right Tool

Different tools do different tasks and what works well for one may not be best for another.

The Ankarsrum is, depending upon which review is believed, a really expensive but mediocre mixer or the mother of all mixers and totally worth the price. Unlike the Kitchen Aid and countless knockoffs, the Swedish mixer rotates the bowl which forces whatever is inside through a series of rollers. For doing things like whipping egg whites, there’s a plastic bowl with some beaters that looked jerry-rigged which they probably are.

There’s an easy explanation for the split reviews and the higher price tag: the Ankarsrum is what the French refer to as a Pétrin, a machine that kneads heavy dough. It has a specific purpose including a heavy-duty motor to match that purpose. Baguettes, pizza, and bagels will come out great in the Ankarstrum where they’ll break the internals of a Kitchen Aid.

However, the Kitchen Aid is what the French call a Robot Pâtissier. As the name implies, its primary purpose is to make pastries, not dough. It’s great at whipping up eggs, cake batter, and all manner of other delicious fattening stuff. There’s a bread hook on it but for the cook who tries traditional heavy doughs, they’ll be disappointed or break their machine.

It’s not that the Ankarstrum is better than the Kitchen Aid or vice-versa; they’re different tools. Sure, you can use one of the jerry-rigged attachments to force the Ankarstrum to do what the Kitchen Aid does, and you can try to make traditional pizza dough in the Kitchen Aid, but soon or later — and, based on countless reviews, probably sooner — you’ll be disappointed.

I just released an exercise/case study that explores the difference between technology innovation and value innovation. I don’t normally pitch stuff for my day job at the INSEAD Blue Ocean Strategy Institute but, if you’re doing work with any firm that’s technology-focused, as many are, I’d strongly recommend it. Of course, there is one important point not there: sometimes it is necessary to focus on engineering, on technology innovation, because a specific task requires it.

We obviously need architects to make buildings that will not leak or collapse. We also want them to be aesthetically pleasing, environmentally efficient, and comfortable to work or live in. A good building will appeal to buyers and nonbuyers. A great builder will build buildings that make competing buildings irrelevant. But, at some point, those buildings must neither collapse, burn down, have their pipes freeze, nor do countless other things that a poorly engineered building might do. The engineering component of an architect is largely invisible unless it is not.

Similarly, there are countless aspects of developing a product or service that aren’t really strategic ideation but are focused on constraints beyond buyer demand. After all, if we could suspend gravity and create a flying car that used no fuel we’d surely sell a lot of units. But deep-diving into this is probably pretty pointless because it’s not going to happen.

Engineering methodologies, like six sigma, may be great for creating engineered products. Nobody wants their stuff to have manufacturing defects, after all. Strategic ideation methodologies, like blue ocean strategy, are similarly great for ideating products and services that customers and noncustomers actually want but aren’t especially good for, say, ensuring the building complies with electrical code.

Both methodologies, like my two types of mixers, were built for a specific purpose. Like the mixers, they can be jerry-rigged for a different purpose and that may even work. However, also like the mixers, it’s really best to focus on what they’re meant to do. Want to mix up some baguette dough? Use the Ankarstrum. How about a batch of croissant dough or a cake? Time to pull out the Kitchen Aid. It’s not that either is better than the other. Rather, they’re engineered for a specific purpose.

I research, write about, consult, and teach blue ocean strategy. I’m a fan and have been for two decades now, since I started using the methodology in the workplace and met the authors of the book (back then, a series of HBR articles). Still, people shouldn’t use blue ocean strategy to conform to the fire code; it’s not made for that and won’t work. Similarly, you shouldn’t use six sigma or any of the alternatives to develop a business strategy: no matter what your six-sigma consultant may say, it’s not made for that.

Use blue ocean strategy to create a product or service and unlock a blue ocean. Then use six sigma or whatever else to make sure every one of those products that rolls off the assembly line, through the app store, or out of the kitchen is the highest quality possible. These frameworks work together; there’s no need to pick and choose.

Start Up That Startup

It's a good time to do new things.

Rachel (her name is changed) is a childhood friend of my sisters. Putting it mildly, the late 20-something likes to party. My wife and I had just finished a major renovation of our house and needed a dog sitter when we went on vacation. “Hire her,” said my sister. “She’s great.” “No parties,” were our parting words. We shouldn’t have been surprised when we saw our brand-new never-used kitchen filled with strangers on Facebook, the dogs she’d been hired to sit wandering lost in a sea of beer cups.

That was over a decade ago and since we’ve watched her on social media as she meandered through life. There was the hippie commune, the short-lived marriage to a man old enough to be her father, a job growing cannabis before that was entirely legal, and a thankfully fleeting fascination with guns that disappeared before anybody got hurt. Social media updates like “woke up naked this morning in a field and can’t remember exactly why: lovin’ life!” were not uncommon.

She eventually moved back to her home state and fell into a marketable enough skill as a bartender. She liked her work and seems to have done well at it, earning enough money to buy a modest house and start to live a reasonably normal life.

Then came COVID. There wasn’t much work for laid-off bartenders and she bounced from thing to thing, doing her best to bring in enough money to feed and shelter herself and her dog.

One day, not long ago, Rachel posted something entirely different “I’ve made more money in the past month than I did in the past two years and it’s doing something entirely legal!” she wrote. Rachel had discovered day trading, especially in crypto, and found her massive following of people online were highly influenced to listen to her recommendations for obscure coins. I thought about warning that stock promotion may be illegal but didn’t. Even with the potential liability, this seemed like one of the more financially and legally sustainable gigs she’d found.

Now, restaurants and bars in her area are looking for workers, and especially experienced bartenders. She isn’t interested: that was her “old life” and she’s found something new. She stopped collecting the unemployment that not long ago kept her housed and fed a couple of months ago saying “too much hassle for too little money.”

Granted, based on historic patterns, Rachel’s newfound career as a day trader may be short-lived. But she realizes that and is already looking into getting more formal securities certifications. It may have taken longer than usual, but Rachel is growing up.

The COVID plague is morphing into an economic rebirth. We hid in our living rooms like a cocoon for over a year. Overworked stressed-out worms crawled in but butterflies are flying out.

As COVID wanes, a generation is weaning out of dead-end jobs and has no intention of returning. Those cooks a restaurant laid off when money got tight? Some opened up shop on their own in dark kitchens while others retrained as coders. The experienced one’s restaurant owners let go when the going got tough are gainfully employed elsewhere. They’re earning higher wages and better benefits than their prior employer ever paid. Your dishwasher’s retrained as welders. The hostess traded her pen for a hammer building houses. The stock person is now an in-demand saucier.

A friend overheard a restaurant owner in a college town complaining McDonald’s was “poaching” his employees by “paying too much.” His state is one that will cut off extended unemployment benefits soon but, the owner conceded, nobody expects that to have a meaningful effect on qualified applicants. The wage differential is already high enough, said the restaurant owner, that anybody who’d “rather work than sit on their ass” is already back to work and the rest probably won’t opt for long hours at low pay served alongside a generous helping of verbal abuse.

As business writer Erik Sherman writes for Forbes, describing those who refuse to take jobs under the old system as a “major uncoordinated labor strike,” there’s a “cannibalistic paternalism on the part of employers that assumes they have a right to drain the last vestiges of energy, life, and nerve from those they consider below.” Their unwillingness to return, coupled with many finding better or at least different employment options, creates a new world.

Mr. Smith’s invisible hand is, paraphrasing Mr. Brooks, doing that voodoo that you do so well by giving some people a pat on the back and others a well-deserved spank on the tuchus.

COVID functioned like an economic forest fire, leaving immense pain in its wake but, as it wanes, new sprouts with plenty of room for growth. That doesn’t mean the world is out of the woods: India and Brazil especially remain in dire shape. But there’s finally a light at the end of the tunnel; Americans aren’t even wearing masks anymore and European regulators are announcing schools can open at full capacity this fall.

Economist Joseph Schumpeter famously wrote about business cycles: “Situations emerge in the process of creative destruction in which many firms may have to perish that nevertheless would be able to live on vigorously and usefully if they could weather a particular storm.”

There are a few misconceptions about these cycles.

The first is that we think of them as somewhat human-made which they often but not always are. The early 80s recession, the dot-com bust, and the financial crisis come to mind. However, COVID is a reminder that we remain human beings subject to natural forces.

The second misconception is more interesting. We tend to think of business cycles affecting firms and, yes, Schumpeter did focus on firms. But the same applies to people. We saw those enormous lines at food banks not long ago. Yet innovation and creation are thriving and moving quickly to more than fix that problem. Many people aren’t unemployed; they’re differently employed in better paying more meaningful work. Rather than destroying a firm, Schumpeter’s fire burnt away the ability to offer poor wages and working conditions, trimming it down like a laser does a tumor.

Post-recessionary periods are historically the very best time to start a business. Today, there’s cheap commercial space, cheap capital, less competition, and enormous demand. Sure, you may have to pay workers more but that’s not necessarily a bad thing because you get to set prices at a level that works to pay them — explaining to customers your prices support better wages for the staff — whereas prior businesses may find long-time customers turned-off by a price increase. If your to-be customers are extremely price-sensitive then you’re probably looking at a red ocean of competition and should pivot to a more sustainable strategy.

None of this is to argue that either COVID or COVID fallout is entirely gone. It still ravages the world and payrolls have yet to catch up in many sectors. However, thanks to vaccines, green sprouts are beginning to blossom. Now is the time to jump on them, to seek out your new blue ocean of opportunity.

Origin Stories: Credit Bureaus

How one man's zeal to end slavery resulted in the modern credit bureau.

Lewis Tappan was a self-made twice failed businessman. By day he worked, along with his brother, Arthur, as a silk wholesaler in New York City. But his real passion was the abolition of slavery, a cause the brothers worked for tirelessly. After yet another business failure — at an age most people were dead or retired — Tappan combined his two passions to create the modern credit bureau. One of his earliest employees was Abraham Lincoln. Altogether, four anti-slavery Presidents worked for Tappan's firm.

I’ve written before about Tappan’s wild story but believe it is one of the least understood and most interesting business origin stories in existence. The impact of his work is nothing short of the modern global credit system. That would be impressive enough but he founded the business at age 53 when the life expectancy for a man was 40 years old. And he did it without letting up at all in his push to end slavery; focused on the famous Amistad case while, at the same time, starting his business (and, oh yeah, being routinely chased, harassed, and firebombed by angry mobs of pro-slavers).

Tappan turns every stereotype about formulas for success on its head. He was way too old, his repeated business failures made him a sky-high risk, he was overtly political and widely hated, his business and business model were entirely new, he was severely undercapitalized, his motivation was for a social good although he was building a for-profit enterprise, and he wasn’t singularly focused. Yet he founded a company that’s lasted 120 years and counting, Standard & Poor’s.

Another Facebook Fail: Toxic Antivaxxers Run Amok

Do the research: millions of deaths worldwide, countless suffering, and trillions of dollars later, Facebook and Google are doing nothing to stop the flood of misinformation.

Googling “antivaxxers on facebook” returns just over two million results, the first being a link to the Facebook page “Anti-Vaxxer.”

This very much active page shows Facebook’s non-dedication to stopping vaccine misinformation and slowing down anti-vaxxers despite the second link, a three-month-old Guardian article promising to do just that.

Ever since Dr. Edward Jenner opened the first vaccination clinic in London, infecting people with the harmless cowpox to build immunity against debilitating and deadly smallpox, vaccine opponents have been spreading fear, uncertainty, and doubt. They see an implicit right to ignore vaccines which mirrors the same implicit right the January 6th rioters saw to overturn an election. In the name of freedom, anti-vaxxers believe they have a right to do wrong.

Make no mistake: refusing to vaccinate oneself is wrong. It’s a boneheaded move stemming from ignorance, selfishness, and paranoia. Are the COVID-19 vaccines well tested? Of course not; they’re far too new. Is that really what concerns them? No. Plenty also reject decades-old vaccines and more than a few even deny that COVID is real.

I know one anti-vaxxer who first claimed COVID isn’t real, then that it was caused by 5G (at a time there weren’t any 5G towers), then that Bill Gates had something to do with it, then that the masks cause oxygen depletion, and now she’s onto something about Agenda 21, Agenda 2030, somebody named Klaus Schwab, the WEF, and the Great Reset. When pushed by somebody far more patient than I am for facts, she argued “this is MY page” a common refrain from those deluded enough to believe they own their small corner of Facebook. Their shrill cry “do the research” means believe my baseless memes or suffer endless ad hominem attacks.

Promises to reign in anti-vaxxers were entirely ignored: they’re running amok spreading misinformation, especially on Facebook. Zuck & Co. — who supported holocaust denial until not so long ago — aren’t doing anything about it despite their pledge to. Worse, Google is actually helping to disseminate the nonsense.

Let’s clear something up: nobody owns their Facebook page or group. Everything on Facebook is owned by Facebook. The website, along with Twitter, YouTube, and all the rest, is a company town. They can shut you down for any reason or no reason at all. Of course, they rarely do. It’s far more common they let crazy people, spambots, and even government agents sow misinformation that harms the well-being of democracy, decency, and public health. Why? Because clicks beget ads and ads are money.

The web and even big tech started out as an almost utopian ideal but, as usually happens, utopia devolved into dystopia when gold flowed. At this point, they could care less about anything besides maximizing engagement and clicks. And if the maximization comes at the cost of an increased body count, a pogrom, and the occasional dictator rising to power then so be it. After all, what’s a touch of genocidal ethnic cleansing as long as the stock price goes up, up, up.

We all know the Steve Ditko/Stan Lee line from the first introduction to Spider-Man, “with great power comes great responsibility.” Maybe neither Zuck nor Pichai read comic books; they don’t seem the types to have much of a sense of humor. Or maybe they’re too buried in their company’s stock tickers to look up and see the mayhem, pain, and body count their laissez-faire attitude comes with, as long as it’s nothing they personally find disagreeable.

Fake anti-vax information is a literal and figurative infection on the world. These people are going to leave us locked up over and over, their arrogance enabling wave after wave of physical and economic destruction. Their notion that they have a “right” to spread disease is straight out of Ayn Rand’s playbook; lots of rights but no responsibility whatsoever to the public. If that sounds like a description of spoiled children to you, it does to me, too.

Would everybody prefer if the COVID-19 vaccines were tested for 30 years? Of course: who wouldn’t. I’d personally prefer if the disease never circulated in the first place. It’s caused enormous damage. Most but not all people survive but plenty are left sick for a very long time; I know a “long-hauler” who has been sick since December. A close friend of my wife’s mom died. Everybody knows somebody who was affected even if they weren’t personally. And, of course, we’ve all been locked up. I’ve never had such bad hair in my life.

By any rational measure, the anti-vaxxers tend to be crazy. But Facebook and Google know exactly what they’re doing letting this nonsense flow and we know the exact reason they allow it: money. Controversy begets engagement which leads to eyeballs and ad dollars, never mind the body count. It was one thing when these were young companies run by inexperienced managers trying to figure things out. Now, they’re long past that stage. Facebook, Google … grow up. Knock it off. Not only the anti-vax messages but all the rest too. And don’t pretend you don’t know what’s going on: as they say in Latin res ipsa loquitor: the truth is apparent. Get your act together unless you want politicians to do it for you.

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