Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France (The Culture and Politics of Health Care Work) (Hardcover)

~ (Author)
Key Phrases: interdependent citizenship, medical syndicats, sory health insurance, United States, Sécurité Sociale, Blue Cross (more...)

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Product Description

Although the United States spends 16 percent of its gross domestic product on health care, more than 46 million people have no insurance coverage, while one in four Americans report difficulty paying for medical care. Indeed, the U.S. health care system, despite being the most expensive health care system in the world, ranked thirty-seventh in a comprehensive World Health Organization report. With health care spending only expected to increase, Americans are again debating new ideas for expanding coverage and cutting costs. According to the historian Paul V. Dutton, Americans should look to France, whose health care system captured the World Health Organization's number-one spot.

In Differential Diagnoses, Dutton debunks a common misconception among Americans that European health care systems are essentially similar to each other and vastly different from U.S. health care. In fact, the Americans and the French both distrust "socialized medicine." Both peoples cherish patient choice, independent physicians, medical practice freedoms, and private insurers in a qualitatively different way than the Canadians, the British, and many others.

The United States and France have struggled with the same ideals of liberty and equality, but one country followed a path that led to universal health insurance; the other embraced private insurers and has only guaranteed coverage for the elderly and the very poor. How has France reconciled the competing ideals of individual liberty and social equality to assure universal coverage while protecting patient and practitioner freedoms? What can Americans learn from the French experience, and what can the French learn from the U.S. example? Differential Diagnoses answers these questions by comparing how employers, labor unions, insurers, political groups, the state, and medical professionals have shaped their nations' health care systems from the early years of the twentieth century to the present day.

From the Back Cover

"In Differential Diagnoses Paul V. Dutton tells the story of two nations over the course of an entire century. This remarkable book is one part history, one part policy analysis, and it is held together by strong conceptual glue. Differential Diagnoses is distinguished by Dutton's smooth, jargon-free writing, its accessibility, its richness of anecdote, its blending of original archival research with synthetic research drawn from several disciplines, and its timely and level-headed diagnosis and prescriptions for change."--Timothy B. Smith, Queen's University

"Paul Dutton exhibits superb scholarship and insight on the evolution of health care financing and organization in France and the United States. His lucid book demonstrates that France's health system is more relevant for the United States than the health systems of the usual suspects--Canada, Germany, and Britain. It should be read by all health policy analysts, scholars, and social reformers who are searching for ways to achieve universal health insurance coverage in the United States."--Victor G. Rodwin, Professor of Health Policy and Management, Wagner/NYU; and Director, World Cities Project, International Longevity Center-USA

"By first exposing the stereotypes and then carefully exploring the distinct histories of health care provision in the United States and France, Paul Dutton provides unique and valuable insight into how both countries can better address their respective health crises."--Jeremy Shapiro, Fellow and Director of Research, Center on the United States and Europe, The Brookings Institution

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Product Details

• Hardcover: 253 pages
• Publisher: ILR Press; 1 edition (August 2007)
• Language: English
• ISBN-10: 0801445124
• ISBN-13: 978-0801445125
• Product Dimensions: 9.1 x 5.9 x 1 inches
• Shipping Weight: 15.2 ounces (View shipping rates and policies)
• Average Customer Review: 4.4 out of 5 stars  See all reviews (5 customer reviews)
• Amazon.com Sales Rank: #825,031 in Books (See Bestsellers in Books)

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7 of 7 people found the following review helpful:

5.0 out of 5 stars French Health Care: An Alternative Model to Single-Payer?, January 2, 2008

By	Joel A. Harrison "PhD, MPH" - See all my reviews (REAL NAME)

Once again with an upcoming election health care shows itself a major concern of the American people. Health care costs are soaring, the ranks of the uninsured and underinsured are increasing, over 50% of bankruptcies are due to medical expenses and employers are dropping coverage. Not only is our system the most expensive by far in the world; but the most complex and bureaucratic. Its costs affects the competitiveness of American firms on the world market and people often seek or retain jobs based on availability of health insurance rather than matching skills and interests, thus lowering productivity. Polls show the American people want change and see the Canadian single-payer system as a model. However, not too long ago the World Health Organization ranked the health care system of France as number 1 with the U.S. in 37th place, something unknown to most Americans until Michael Moore's recent film, Sicko.

So why not consider French health care as a possible system to model after rather than Canada ? For many, the answer is obvious. Americans would never tolerate "socialized" medicine. But is France 's health care "socialized medicine?" Paul V. Dutton's timely book answers this question with a resounding, NO! It turns out that no other country on the face of this earth has as similar 18th Century liberal values of individual freedoms and responsibility to those of the U.S. as France and it shows in their health care system. "Socialized Medicine" is for the French as anathema as it is to us. Yet France has managed to attain universal coverage, high quality medicine, and no waiting lines in a system of private fee-for-service medicine that Americans could only dream about and at lower cost. In their laws, basically etched in stone, are guarantees of individual choice of doctors and hospitals, medical decisions to be made between doctors and patients with no third party interference, strong protections for doctor-patient confidentiality, and direct payment of bills by patients. But isn't this exactly what the American medical profession has fought for over many years? This is the story that Dr. Dutton's book weaves in a well-written fascinating account of how two nations with similar values, especially within their respective medical professions developed their respective health care systems.

Certain key decisions sealed their respective fates. In France , the medical profession rather than fighting some form of government required universal health care, supported it with the strong proviso of legal guarantees that are the bedrock of their private fee-for-service system. In the U.S. , the medical profession fought tooth and nail against any government involvement developing instead the non-profit Blue Crosses and Shield's with community ratings and no exclusions due to pre-existing conditions. Only then did for-profit insurance companies enter the health care market, cherry picking healthy workers with offers of lower premiums to their employers, eventually forcing the Blue's to also adopt experiential ratings. The American medical professions exaggerated fears of government led to support for what has become our fragmented dysfunctional for-profit system. As has been said, American doctors' fear of socialism led to their being blind-sided by capitalism. As a result, Americans most often must choose their doctors based on which insurance company their employers have chosen, sometimes forced to change doctors each year as coverage changes, doctors have to battle with insurance company bureaucrats for approvals of diagnostic and surgical procedures, and so it goes.

One point that comes across clearly in Dr. Dutton's book is that our current health care system was not based on any plan or, for that matter, market model. Reading his book clearly indicates the opposite. For those mainly interested in the U.S. health care system and its development, this book is a must. A series of short-term decisions and serendipitous events, e.g. World War II, led to our currently dysfunctional costly system. However, as Dr Dutton's book clearly shows, looking and comparing the development of our system with another allows for much greater understanding and depth as well as a potential model for us.

Unfortunately, Dr. Dutton does not include a chapter actually devoted to describing the French health care system, but instead describes its development throughout the book. I hope that the next edition of his book will include such a chapter. In the meantime, I would urge him to write it and place it on his website.

I did find on the web a somewhat dated (2001) description of the French health care system by a British think tank, Civitas, "Health Care in France and Germany ," which can be found at http://www.civitas.org.uk/pdf/cs17.pdf. However, it does not describe how drug prices are kept reasonable, how negotiations of doctors fees and hospital costs are conducted, how high tech is adopted, etc. But briefly, everyone who is employed in France belongs to one of several insurance "caisse" similar to our original Blue Crosses. Salaried employees belong to one, school teachers to another. The boards that govern these "caisse" are composed of representatives of government, employers, and workers. Rather than based on community ratings, they are funded by a dedicated percentage of paychecks similar to our Medicare tax, with employers and employees each contributing. The government pays the "Medicare tax" for those who are unemployed. As with Medicare, and the original Blues, a set fee structure is negotiated every year. This structure doesn't completely cover most care, so, as with Medicare, the French have a supplementary insurance that covers co-pays which can be purchased from either for-profit or not-for-profit companies. The choice of companies is completely up to the individual, but the premiums are taken out of the employee's paycheck as a percentage. Neither the French "caisse," nor the supplementary insurances can discriminate due to pre-existing conditions. Patients are required to pay normal doctor bills up front in keeping with the individual responsibility fee-for-service-system and are then reimbursed. Nowadays, for many, the monies are electronically placed in their respective bank accounts. Hospitals are paid directly, but patients are required to pay a minimum daily fee. However, as the seriousness or chronicity of the condition increases, co-pays are eliminated and patients aren't required to pay first and wait for reimbursement. By taking a fixed percentage based on pay and having everyone in the system, the complex costly actuarial process and multiple policies of the U.S. don't exist. Since all the "caisse" pay the same, billing is simplified.

I would like to share one little anecdote which I found both amusing and informative from the Civitas paper. They interviewed people about their experiences. One elderly woman complained about her hospital care. She had a private room in a modern equipped hospital with a choice of three entrees per meal. She could have chosen other hospitals, but she chose one close to her family. So what was her complaint? Personnel sometimes entered her PRIVATE room without knocking and she thought that was rude. Ah, if that was the only complaint one heard about our health care system!

So back to Dr. Dutton's book. For anyone interested in health care politics, health care reform, for insights into how our system developed, and for a possible model for reforming our system, Dr. Dutton's book is a fascinating read and a must!

5 of 5 people found the following review helpful:

4.0 out of 5 stars A useful comparison of the US and French systems, May 13, 2008

By	Michael T Kennedy (Mission Viejo, CA USA) - See all my reviews

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This is a useful book. Like another reviewer, I wish the author had included a more thorough description of the present French system. My understanding is that electronic medical records, to some extent at least, are embedded in the health care card carried by members. When they visit a doctor's office, a swipe of the card in the reader, conveys some information (I wish I knew how much) to the doctor's office record and, at the same time, deposits the Securite Sociale payment in his practice account. It is interesting to see how much the French have preserved the private fee-for-service system. The author decries this a bit, emphasizing the risk of excessive utilization in the fee-for-service system. That is definitely true but the prepaid system of the HMO has the mirror-image risk of denying service to reduce expense. Buyers of new home prepaid service plans know how difficult it can be to get the service technician to come out to fix the dishwasher when he has already been paid.

The parallel history format of the book is good and, while I am very familiar with the history of US health care, it was valuable to see the contrast with the French system. The unique circumstance that had a lot to do with the diversion of the French system from ours was the loss to Germany in 1940 and the subsequent period of Vichy rule. All the older structures of government and the hierarchy of the medical profession were upset and replaced by a diluted version of the Nazi regime. The 1944 invasion and liberation placed the De Gaulle organization in charge and it was very interesting to learn that health care reform was a concern of the Free French even during the period of exile from 1940 to 1944. Again, the intervention of President DeGaulle in 1960 to establish fixed fee schedules was new to me and makes the two chapters, numbers five and six, the best part of the book.

I have a few disagreements with the author. He is obviously an enthusiast for the failed Clinton Health Plan of 1994 but he ignores the principle reason why it failed. He is correct that union opposition has been a barrier to reform in both countries, prolonging the employment link to health insurance far beyond the time when it made sense. He does not inform the reader, however, that the secrecy and the failure to include any non-academic providers in the task force preparing the plan led to widespread distrust and opposition. Additionally, the criminal penalties attached to practice outside the Clinton cooperatives alienated physicians completely. Having said that, I generally support his history of the US system although Paul Starr's book is more complete. He does misstate the position of the American College of Surgeons on a national health plan for the US. I have been a member of the College since 1972 and it first testified in favor of a national health plan in 1938. The fierce opposition he describes as coming from the AMA (and he is correct) was always the position of general practitioners. The Resource Based Relative Value Scale that he describes as part of Medicare reform in the mid 1980s was less a parallel of the DRG system and more an attempt to de-emphasize highly technical care. It is a form of rationing by devaluing the most time consuming and skill dependent procedures in surgery. As a matter of government policy, it is certainly within the power of government to impose but it has been dishonestly described. The author, not being a physician, may not be aware of the history of that particular development.

I wish the details of the present French system had been more complete as it may offer a better alternative as we seek new ideas for health care reform. The history was well done and he knows his subject quite well, as I can judge from his description of the US system. I recommend it.

4 of 4 people found the following review helpful:

3.0 out of 5 stars A much needed work, April 24, 2008

By	Newton Ooi (Phoenix, Arizona United States) - See all my reviews (TOP 1000 REVIEWER)    (REAL NAME)

Bring up anything French to most Americans, and one gets jokes, frowns, insults and other demeaning comments. Whether it be French fries, Americans winning the Tour de France, or French women, Americans tend to look down on France. This is regrettable, as many aspects of French history have paralleled events in American history. This book by Professor Dutton at the University of Arizona examines the evolution of the medical systems in France and America over the course of the 20th century. Specifically, the book looks at the economics and politics of health care in both countries; such as major laws and regulations, the role of third-party insurers, the role of employer-based health care, conflicts between doctors and hospitals, and the unending debate over private fee-for-service and socialized medicine. Surprisingly, the debates in the US on all these issues have paralleled those in France, often occurring in the same decade. The book is written in chronological order, and reads like a history book. The text is readable by those inside and outside the medical community, and requires almost no economic or medical knowledge to understand. Given the topic, this book is very good and informative, and quite unique in providing an in-depth comparison of two countries.

The book does have two drawbacks. First is the minimal coverage it gives of medical education in the two countries. This is very important, and might help the reader understand how paths have diverged in the two countries. Second, the book focuses almost entirely on doctors; little mention is made of nurses, pharmacists, dentists, and the vast community of scientists and supporting staff who are responsible for research and development. For these two drawbacks I give the book three stars, and not five.