Paul Krugman et le “modèle français”

L’économiste Paul Krugman, éditorialiste du New York Times, fait une sortie tonitruante en faveur du modèle socio-médical des pays à forte intervention publique, particulièrement la France (figurant comme son modèle favori aux côtés de l’Allemagne et du Canada). C’est une appréciation intéressante à l’heure du débat en cours autour de l’“Europe libérale”, dans la campagne référendaire. Elle concerne aussi bien la valeur du système basé sur l’intervention publique que la rentabilité du système américain, basé sur l’intervention privée et qui parvient pourtant à des dépenses publiques supérieures au précédent.

« The countries that have something to teach us are those that do not pinch pennies to the same extent — like France, Germany and Canada — but still spend far less than we do. (Yes, Canada also has waiting lists, but they are much shorter than Britain's, and Canadians overwhelmingly prefer their system to ours. France and Germany do not have a waiting list problem.)

» Let me rattle off some numbers. In 2002, the latest year for which comparable data are available, the United States spent $5,267 on health care for each man, woman and child. Of this, $2,364, or 45 percent, was government spending, mainly on Medicare and Medicaid. Canada spent $2,931 per person, of which $2,048 came from the government. France spent $2,736 per person, of which $2,080 was government spending.

» Amazing, isn't it? U.S. health care is so expensive that our government spends more than the governments of other advanced countries, even though the private sector pays a far higher share of the bills than anywhere else.

» What do we get for all that money? Not much. Most Americans probably do not know that we have substantially lower life-expectancy and higher infant-mortality figures than other advanced countries. It would be wrong to jump to the conclusion that this poor performance is entirely the result of a defective health care system; social factors, notably America's high poverty rate, surely play a role. Still, it seems puzzling that we spend so much, with so little return.

» A 2003 study published in Health Affairs (one of whose authors is my Princeton colleague Uwe Reinhardt) tried to resolve that puzzle by comparing a number of measures of health services across the advanced world. What the authors found was that the United States scores high on high-tech services — we have lots of MRIs — but on more prosaic measures, like the number of doctors' visits and number of days spent in hospitals, America is only average, or even below average. There is also direct evidence that identical procedures cost far more in the United States than in other advanced countries. The authors concluded that Americans spend far more on health care than their counterparts abroad — but they do not actually receive more care. The title of their article? “It's the Prices, Stupid.”

» Why is the price of U.S. health care so high? One answer is doctors' salaries: Although average wages in France and the United States are similar, American doctors are paid much more than their French counterparts. Another answer is that America's health care system drives a poor bargain with the pharmaceutical industry.Above all, a large part of America's health care spending goes into paperwork. A 2003 study in The New England Journal of Medicine estimated that administrative costs took 31 cents out of every dollar the United States spent on health care, compared with only 17 cents in Canada. »

Mis en ligne le 20 avril 2005 à 20H05