[This is G. Sallust, and today I’m doing a [hopefully] short post on health care, a subject that’s bedeviled our politics for years. More specifically, we’ll talk about the Patient Protection and Affordable Care Act[1], popularly known as Obamacare, passed in 2010. As you may know, we did a lengthy blog a while back detailing how that was done, and the rather clownish debate that accompanied the complex parliamentary procedures employed by both sides.[2]  As I recollect, the Republicans took the position that anyone who supported the bill probably was a Marxist, while the Democrats said that basically the Republicans just wanted to kill the poor. The “debate” was not a consensus-building exercise.]

As we all know Obamacare finally did pass, and thereafter Republicans in the Congress voted repeatedly to abolish it. None of these efforts got by President Obama because a President has the power to veto legislation, and it’s very hard for Congress to overcome one of those even when Conservatives wish it so. [3]  My take on President Trump is that he is more moderate on Obamacare than the far right wing of his party really likes. He’s willing to “repeal and replace” the program, not just do away with it. We’ll find out what that means when the Republican House and Senate produce legislation that they both agree to. If he signs it, that act will define his Administration’s policy.

Best Care in the World?

Back in 2009, 2010 one of the arguments against Obamacare was that we already had the best medical care in the world, so why tamper with it by regulating service and letting more people in? That would have been a good argument if it were true, but it wasn’t. In 2000 WHO [the World Health Organization] published a report that studied and ranked health system performance around the world.[4]   France was ranked # 1 in “Overall Health System Performance”; Germany, # 25; and the U.S., # 37.[5]

When WHO issued its 2010 report, in time for the great debate on healthcare here in the U.S., it had even more embarrassing facts for people who thought we were the greatest. [6] Just looking at the same 3 countries, France, Germany and us, it’s obvious that the people there live measurably longer than we do here. Our life spans are OK, I guess, but definitely we’re not # 1, ever. Take a look at these statistics from 2000 and 2008:

Life Expectancy at Birth in 2000, 2008, for France, Germany and the United States


  • CY 2000: men 75 years; women 83 years; average 79 years;
  • CY 2008: men 78 years; women, 85 years; average 81 years;


  • CY 2000: men 75 years; women 81 years; average 78 years;
  • CY 2008: men 77 years; women 83 years; average 80 years.

United States   

  • CY 2000: men 74 years; women 80 years; average 77 years;
  • CY 2008: men 76 years; women 81 years; average 78 years[7]

So did things get better in 2015? They did so marginally; but we were still last of the 3, and again men were dying sooner than women:

Life Expectancy at Birth in 2015 for France, Germany and the U.S.


  • CY 2015: men, 79.4 years; women, 85.4 years; average 82.4 years;


  • CY 2015: men, 78.7 years; women, 83.4 years; average 81.0 years;

United States

  • CY 2015: men, 76.9 years; women, 81.6 years; average 79.3 years. [8]

U.S. Spending

But in spite of our poor performance compared to France and Germany, we do lead everyone in one important area. We spend more on healthcare than anybody else in the world.  And how do I know that? Well, the CIA keeps track of that kind of thing. According to the CIA World Factbook[9],

  • The U.S. spent 17.1 % of its GDP on healthcare as of 2014
  • France spent 11.5 % of its GDP on healthcare as of 2014
  • Germany spent 11.3% of its GDP on healthcare as of 2014

So we lead the pack overall in spending, if not in results. After all, the spending numbers are expressed as a percentage of Gross Domestic Product; our GDP is the largest in the world, at least for now; and we spend the highest percentage of GDP on healthcare, so we are, by definition, the big spenders of the planet. We just don’t get as much for our money as others, like the French seem to do. And costs here are going up. If you don’t believe that, take a look at your medical insurance premiums, deductibles and co-payments. Word is, they’ll rise again, unless the insurance companies drop their medical coverage altogether, or the Government steps in with a subsidy. Is this a great country, or what?

And by the way, current news is that the new president of France, Emmanuel Macron, is looking for ways to improve French health care.[10] He seems to think that the French system is a bit too expensive. Hopefully he won’t ask us for advice, or if he does so to be diplomatic, he won’t take it. Why would he want to ruin the better [and less expensive] French system by adopting our mistakes? It would be like sending American wine to France and expecting people there to like it.

Or perhaps he might decide to adopt the good parts of our system and forget the rest. If he does that, and can identify them for us, then perhaps we should take his advice, rather than vice-versa.  But actually I don’t think our economists, or politicians, would ever accept ideas from a foreigner that contradicted their own. We are the greatest, right?



[1] The official citation is Pub. Law 111–148, Patient Protection and Affordable Care Act, 124 Stat. 119 – 1025 (March 23, 2010).

[2] See the blog of 09/19/2013, Health Care Again and Again, available at https://opsrus.wordpress.com/2013/09/19/health-care-again-and-again/

[3] See U.S. Constitution, Article 1, §7. For an interesting article on the veto, see Cameron, The Presidential Veto, available at https://www.princeton.edu/~ccameron/The%20Presidential%20Veto%20v3.pdf

[4] See WHO, The World Health Report 2000, available at http://www.who.int/whr/2000/en/.

[5] Id. at p. 153 – 155.

[6] See WHO, World Health Statistics 2010, available at http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf?ua=1

[7] Id. at Mortality and Burden of Disease, p. 50 – 54.

[8]  By the way, for future reference you can download the most recent data from the WHO Global Observatory, at http://www.who.int/gho/publications/world_health_statistics/en/ These numbers are taken from Annex B, Part I of the 2015 data.

[9] This is another Government document that’s not a secret, but this time it’s intentional. You can  find it at  https://www.cia.gov/library/publications/the-world-factbook/fields/2225.html#fr

[10] See The Lancet, Casassus, Macron’s vision for the French health system (13 May 2017), available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31268-0/fulltext?elsca1=etoc