Prague Twin

Wednesday, July 04, 2007

Health Insurance

First of all, my apologies for being absent for so long. I feel pretty bad about it, but what can I do? I've just finished my most recent job and I had to move my things from my bachelor pad up in Liberec (60 miles north of Prague) to my real residence here in Prague. In between I've been going to interviews (I have already been offered one job), and trying to keep up with my studies (and doing a poor job of it).

So this post is about health insurance. Here in the Czech Republic, the health system is a confusing mix of private and public. There are a few insurers, but the largest is a state-run enterprise. Doctors are mostly private, but they generally are paid through the insurance programs which somewhat limit the scope of the treatment. Dentists that conform to the rules and have low co-pays are to be avoided at all costs. I pay cash for dentistry, but it is still nearly free compared to what I am used to in the states (for example, I had oral surgery last year because of an infection around the roots of two teeth which cost me $200).

As far as regular doctors go, generally people don't pay anything, although sometimes you have to pay for medications. This system is not perfect, but for the cost, it is amazing.

The Cost

Medical insurance is paid along with payroll taxes, the employer and employee paying nearly equal parts. So as your pay goes up, so does your insurance. Any government regulated program will probably have to have something like this, otherwise, the indigent simply cannot afford to pay. It is required by law that everyone has insurance (children under 5 are free). Now that I am unemployed, I was required to register to pay my own insurance. I now have insurance for almost exactly $50 per month.

I think I'm getting a pretty good deal.




38 Comments:

  • That's an interesting system. Sounds like it works an you're happy with it.

    It seems like there are almost as many ways to provide universal health care as there are things that can possibly go wrong with the human body. Funny that the US, being the greatest country the world has ever seen and all, can't figure out how to implement even one.

    By Anonymous abi, at 4:47 PM  

  • praguetwin, the CIA has the following to say about the Czech economy:

    "The Czech Republic is one of the most stable and prosperous of the post-Communist states of Central and Eastern Europe. Growth in 2000-05 was supported by exports to the EU, primarily to Germany, and a strong recovery of foreign and domestic investment.

    Domestic demand is playing an ever more important role in underpinning growth as interest rates drop and the availability of credit cards and mortgages increases.

    The current account deficit has declined to around 3% of GDP as demand for Czech products in the European Union has increased. Inflation is under control. Recent accession to the EU gives further impetus and direction to structural reform.

    In early 2004, the government passed increases in the Value Added Tax (VAT) and tightened eligibility for social benefits with the intention to bring the public finance gap down to 4% of GDP by 2006. However, due to significant increases in social spending in the run-up to June 2006 elections, the government is not likely to meet this goal.

    Negotiations on pension and healthcare reforms are continuing without clear prospects for agreement and implementation.

    Privatization of the state-owned telecommunications firm Cesky Telecom took place in 2005. Intensified restructuring among large enterprises, improvements in the financial sector, and effective use of available EU funds should strengthen output growth.

    By Anonymous no_slappz, at 5:27 PM  

  • abi, you wrote:

    "It seems like there are almost as many ways to provide universal health care as there are things that can possibly go wrong with the human body."

    You, like everyone else who embraces the idea of "universal healthcare" refuse to acknowledge that every "universal healthcare" program in the world depends on the rationing of healthcare services.

    If every form of treatment for every medical problem were available to every American on demand, the country would go broke.

    Every country offering these broad-based programs makes trade-offs between quantity and quality.

    You wrote:

    "Funny that the US, being the greatest country the world has ever seen and all, can't figure out how to implement even one."

    There are 300 million Americans, but only 10 million Czechs. The Czech republic is becoming more prosperous. Rising prosperity also means the cost of healthcare is increasing. The government is going to put more of those costs on the backs of individuals who are the direct recipitients of those formerly inexpensive services. Or the government will cut back on services.

    In any case, it is much easier to handle the healthcare needs of 10 million people living in a country the size of South Carolina that it is to develop and manage a single system for 300 million Americans.

    The Czech Republic is interesting in another way. The median age in the country is about 40. In other words, the population is relatively old. The aging population will require a lot of healthcare services. Geezers will run up the bills in a big way. The small group of youngsters in the country will resent the taxes they will pay to care for the oldsters.

    Meanwhile, the Czech population is not growing. Without an increasing population, it is tough to increase spending on social programs, like those that provide healthcare services.

    By Anonymous no_slappz, at 5:43 PM  

  • PT,

    In my area, when it comes to medical assistance and denistry you have to be very selective of who you choose. There's not a lot of choice and most of those who do accept medical assistance do so because they cannot get enough patients the "normal" way; yet, they're still back-logged more often than not.

    A conscientious young graduate worked hard to start up a clinic to give the poor a reasonable service. He cannot do everything, and he too is back-logged, but he actually cares. He doesn't under-estimate his clients intelligence, and he believed me when I told him that the a significant portion of the damage to my teeth were the results of a particular practioner's "artistry."

    He opened his practice up with the help of various grants (national, state and county grants) and provides his services regardless of one's ability to pay. Unfortunately, he's unique in this area and has had difficulty convincing anyone else to join him in providing services in this manner. Perhaps a more national, socialized method would make his efforts more practical and make it more attractive for others to join in and provide quality service to those who don't usually have access to such care.

    By Anonymous Stephanie, at 10:15 PM  

  • stephanie, you wrote:

    "Unfortunately, he's unique in this area and has had difficulty convincing anyone else to join him in providing services in this manner."

    In other words, other healthcare providers in the area are unwilling to work for free.

    You wrote:

    "Perhaps a more national, socialized method would make his efforts more practical and make it more attractive for others to join in and provide quality service to those who don't usually have access to such care."

    Again, as you have noted in the preceding paragraph, the issue is payment for services. You're advocating that taxpayers should pay doctors on behalf of those unable to cover their own medical bills. Okay. But at what price?

    Medicaid reimburses doctors at fixed rates, which many doctors consider insufficient. Is it a surprise that doctors show limited interest in serving the poor when the low pay impinges on their lives and the lives of their family members?

    Some states offer free or subsidized medical training for people who will serve in remote areas for a couple of years after graduating. A high school classmate of mine went to medical school in a joint program involving Idaho, Montana, Alaska and Washington.

    Nevertheless, I think it is unrealistic to expect that there are lots of doctors who spent much time and money, and who worked very hard in medical school, who will spend a lifetime working for peanuts.

    By Anonymous no_slappz, at 12:48 AM  

  • no-slappz,

    "But at what price?"

    How 'bout at the price of a system that works? The point (which you obviously missed) is not to illustrate that more people should just do what he does. That obviously wouldn't work, because most people either get into the medical practice to earn gobs and gobs of money, or they need to earn gobs and gobs of money to pay off the expenses of getting the education they actually wanted. Both exist and both make two very different kinds of practioners. (A problem the free-market has failed to address, but instead tends to exasperate.) The denist I describe is a truly exceptional type that actually, genuinely wants to help people -- obviously a foreign concept to you.

    No, what I was trying to illustrate is how our piece-meal system does NOT work in this area. There are too few service providers, all of which are over-booked, most of which provide poor quality services. They people who do the work that others don't want to do, don't get fairly compensated and need grant money to stay afloat. He does get paid, but he does not get paid what he could get paid in a private practice.

    The system does not work. While you obviously don't care about those who must cope with a broken system, there are those who do -- and guess what, they pay taxes! So, the point which you so obviously missed, is that I was offering a contrasting description of our broken system to PT's imperfect system.

    I was not advocating a system in which doctors or dentists work for nothing; I was illustrating a system in which dental care was difficult or impossible to procure, that was to contrast the description PT posted.

    By Anonymous Stephanie, at 1:10 AM  

  • Seems that a good, cheap healthcare system requires doctors whoo don't need 200K/yr in income. Also, I don't think you can have a system that provides large malpractice awards. It would be interesting to see some statistics on malpractice cases, although I am guessing it is almost non-existent. I sure can't figure out what makes healthcare so horribly expensive in the US. The problem is, those who are actively looking at why it is so expensive can't figure it out either.

    By Blogger Publia, at 1:52 AM  

  • stephanie, you wrote:

    "(A problem the free-market has failed to address, but instead tends to exasperate.)

    You and many others confuse EXASPERATE with EXACERBATE.

    That aside, you want a medical system that is like the Post Office. One that delivers basic services to everyone in the country at 41 cents per letter. But you seem to think that highly skilled people who spent years obtaining the professional credentials would work for wages that the 41-cent stamp would cover.

    It's not a matter of having a lot of outstanding student loans from med school. Some people do. Plenty don't. You can be sure doctors coming to the US from other countries don't.

    Doctors may have their compassionate side, but they are also competitive people who believe in receive just compensation for their services. No government program will pay that well.

    Hence, we have Federal Express and UPS, two organizations that charge a lot more for specific services that are no longer regulated by the US Postal Service.

    You wrote:

    "No, what I was trying to illustrate is how our piece-meal system does NOT work in this area."

    And of course the fault lies with "the system". The problems couldn't have anything to do with individual decisions that add up to a situation in which some people have put themselves almost out of reach of healthcare professionals. So let's blame the system instead of thinking about HOW it works and HOW to benefit from the existing structure.

    You wrote:

    "There are too few service providers, all of which are over-booked, most of which provide poor quality services."

    One reason the Post Office loses money is that it must provide mail service to everyone in the country. Almost everyone receives his mail at home. Not many people have to drive to the Post Office to collect it. That bit of generosity is expensive. With medical care, it's a lot more expensive.

    You wrote:

    "They people who do the work that others don't want to do, don't get fairly compensated and need grant money to stay afloat."

    Doctors are human. A few may want to work in rural settings. But most are professionals who want exciting professional challenges. Even higher pay is unlikely to lure competent doctors to outlying areas.

    You wrote:

    "He does get paid, but he does not get paid what he could get paid in a private practice."

    Most doctors I've known work in cities. They often volunteer their services in poor areas on a regular basis. I knew one doctor from Charleston, West Virginia. At one point in his career, he spent a lot time working with miners. But he eventually had five kids and it cost a bundle to send them to college. So, as you can imagine, the work with the miners was not a permanent thing.

    That's how it is. I think you want to alter the behavior of other humans so they will accomodate you. That's not reasonable.

    By Anonymous no_slappz, at 2:43 AM  

  • Publia,

    You have hit on a very important point. A highly educated society creates a lot of doctors, and they are paid very little. Yet, there is steady stream of them.

    Secondly, as you rightly guessed, malpractice is nonexistent.

    These two things contribute GREATLY to the overall low-cost of healthcare here.

    Stephanie and No_Slappz,

    I'll get back to you....

    Cary on.

    By Blogger Praguetwin, at 2:47 AM  

  • no-slappz,

    This thread cannot possibly cover an exhaustive look at this very complex issue, so I was not trying to cover every (or most) angles this issue requires for an equitable solution to be found. That being said:

    "You and many others confuse EXASPERATE with EXACERBATE."

    Duly noted. I usually don't, however I usually don't let my son (who's learning how to type) watch me while I blog. It was distracting. Looking over my post, I caught a few other errors.

    *shrugs*

    It's not really material to this issue so we'll move on.

    "But you seem to think that highly skilled people who spent years obtaining the professional credentials would work for wages that the 41-cent stamp would cover."

    No, actually I believe that an equitable system that provided universal health care would need to factor in and compensate for the scholastic costs of such a field of pursuit, perhaps even making a way for the education system that teaches doctors to be more affordable itself. There would almost certainly need to be an emphasis on preventative medicine, as well as less expensive but effective treatments that address problems in the early stages. A lot of medical expenses could be reduced or eliminated that way, or so I'm told by people in the medical field. Like I said, I was not trying to do a comprehensive analysis -- that requires more expertise than either of us have, extensive research, and a lot more space. However, I will assert that just because there are no solutions that would be both easy and equitable doesn't mean there are no equitable solutions.

    "Doctors may have their compassionate side, but they are also competitive people who believe in receive just compensation for their services."

    That may be how the US practices medicine now, but it's not a universal truth. And since what we pay for medical services does not all go to compensate doctors they can receive "just compensation" while lowering the costs involved. It needs to be done equitably, across the board, correcting the entire system; instead of the piece-meal band-aids Congress likes to dole out to pander to the various interests while pretending to demonstrate concern for their constituents. I never said anything that implies, other than in your own mind, that all doctors should take a huge pay-cut. That's your non-solution, not mine.

    "So let's blame the system instead of thinking about HOW it works and HOW to benefit from the existing structure."

    Okay, show me how that works. Really -- I described the problems, now tell me how exactly it's my fault. Please.

    "With medical care, it's a lot more expensive."

    That analogy is completely false. We do drive to receive services. We wait a half hour (or more) for a fifteen minute visit (for a regular doctor's visit). They do not come to us. They file us in, they file us out. That's even more true for denistry and other extensive services, but the time in tends to be longer because more direct attention is needed.

    How, exactly, does that compare with the USPS delivering mail?

    "A few may want to work in rural settings."

    Yeah, and I live in a city, so what does that have to do with anything? It's not Chicago or New York City, but guess what -- a lot of medical practioners work outside the big cities.

    "I think you want to alter the behavior of other humans so they will accomodate you."

    No, I want to look at health care systems that work better than ours, see how they do it, and adapt their basic structure to our situation. Right now, myself and my family are covered. While the system may not work very well, we get medical care. However, there is a lot of people who have no access to medical care because of the way our medical system works. You can blame them; I don't. You don't seem to care; I do.

    You seem to want things to continue plugging away as they are and resist any change. However, I know things could be better, and I'm interested in seeing just how that could come to be.

    By Anonymous Stephanie, at 3:48 AM  

  • Just adding my 2 cents worth - agreeing with Publia and PT, part of the "problem" with "the system" is not so much the Dr's wanting to make lots of bucks - - it's the FOR PROFIT insurance companies. They are the ones who dictates most often the kind of healthcare the American get or DON'T get! AND the price of malpractise insurance that Dr's HAVE to carry, so they won't get their butt's sued off for every little thing that might possibly go wrong - which could be much!!

    DR's are compassionate for the most part, and usually don't go into the medical field to make tons of money, and are highly overworked people. And unless you're in a speciality, which often requires even MORE mal-practise insurance, most Dr's, especially young ones don't get all that high of pay when it comes right down to it.

    It's NOT the Dr's it's the INSURANCE COMPANIES!! They dictate, medical care by what THEY will pay for - not by what the patient NEEDS or the Dr WANTS for their patients. The insurance companies are involved to make the bucks, not the Dr's. But of course there are exceptions. But let's put the blame where the fault lies.

    IF there was national healthcare, the insurance companies, not the Dr's would be put out of business by lack of profit.

    By Anonymous Diane, at 6:29 AM  

  • stephanie, you wrote:

    "I believe that an equitable system that provided universal health care would need to factor in and compensate for the scholastic costs of such a field of pursuit, perhaps even making a way for the education system that teaches doctors to be more affordable itself."

    In your own meandering way, you have said the government should cap the incomes of doctors. In short, that's illegal in this society.

    You wrote:

    "There would almost certainly need to be an emphasis on preventative medicine, as well as less expensive but effective treatments that address problems in the early stages. A lot of medical expenses could be reduced or eliminated that way..."

    What is "preventive medicine"? I think you have picked up some phony jargon.

    I've listened to public services messages all my life. DON'T SMOKE. DRINK RESPONSIBLY. PRACTICE SAFE SEX.

    I hope these messages help. But the subtext of your comment boils down to state control of personal behavior.

    In your Universal Healthcare plan, would you deny medical insurance to a smoker? Almost 100% of emphysema and lung cancer cases develop in smokers. Hence, cutting off coverage might persuade them to stop smoking. That would seem to be an excellent form of "preventive medicine." However, we both know things will never work that way.

    Would your plan refuse coverage to gay males? Or intravenous-drug users? Those two classes of individuals account for almost all HIV and AIDS cases.

    Smoking, dangerous sexual practices and drug use are all activities willingly undertaken by individuals. The subsequent diseases related to these practices are therefore not the result of some unfortunate genetic lottery.

    Would your healthcare plan cover all forms of human folly? Or do you think we should ration healthcare to those who live sensibly?

    By Anonymous no_slappz, at 4:31 PM  

  • praguetwin, you wrote:

    "You have hit on a very important point. A highly educated society creates a lot of doctors, and they are paid very little. Yet, there is steady stream of them."

    First, are you referring to the Czech system? If so, the Czech system is a bit too new for a lot of analysis.

    Second, how advanced is the Czech system? Is it considered "World Class"? Do people travel there in search of better treatment? I doubt it.

    Or, is the system good with the basics but lacking in advanced areas?

    What are the leading health problems in the Czech republic? Are the major problems related to personal practices that can change?

    You noted:

    "Secondly, as you rightly guessed, malpractice is nonexistent."

    Are you suggesting that Czech doctors don't make mistakes?

    A healthcare system that deprives patients of the right to challenge decisions and seek compensatory damages for botched work is a system that accepts quacks and incompetents. Such a system will NEVER evolve in the US.

    Without reaping huge rewards from malpractice lawsuits, Democratic presidential candidate John Edwards would be just another hick lawyer. Does anyone think this clown would back a healthcare system that would prevent the transference of huge sums to lawyers? He loves health insurance companies. They made him wealthy.

    By Anonymous no_slappz, at 4:46 PM  

  • diane, you wrote:

    "IF there was national healthcare, the insurance companies, not the Dr's would be put out of business by lack of profit."

    Really? Okay. Tell me how this works. And think about this. Public education is controlled by the state governments. Despite ever increasing sums of money spent on public education, the results stink.

    The public school system in every state of the union is deeply flawed.

    Why is it flawed? Because the government does not allow competition.

    Meanwhile, private schools exist. They operate under somewhat different principles. Almost all parents are pleased with the results of private-school education. But those parents must pay twice. Once with property taxes to support the existing crappy public schools, and they pay a second time with hefty tuition bills from the private schools.

    For what reason would you think the federal government would succeed with a national healthcare program when the individual states can't run successful school systems?

    You can be sure that running a school system is simpler than running a massive healthcare program.

    By Anonymous no_slappz, at 4:54 PM  

  • NS,

    You really have a knack for being so sure of things that you are completely wrong about, it is truly astounding.

    I'll just focus on the comments made directly to me....

    Yes, I'm talking about the Czech system, and no I don't think that nearly 20 years under the current system, and centuries before that from which the current system evolved is too new for analysis.

    Major health problems here are the same as anywhere else. Some could be mitigated through life-style changes, many can not.

    I'm not suggesting that doctors don't make mistakes, but simply that there are certain payouts for certain things that happen which you probably wouldn't agree with.

    Getting to Dianne's point, it is the lack of recourse against doctors who make mistakes that helps keep costs down. Yes, some people get hurt because of this. If a doctor makes a mistake on me, I do not become a millionaire. The same is true if I fall in a hole on a public street. Accidents happen, and liability is contained. However, other doctors will fix me free of charge should a doctor make a mistake, or if I fall in a hole.

    Getting to the education question, it is the tradition of education (not the amount spent) that supports the system. Until doctors can be trained for a reasonable amount of money, their fees will remain unreasonable.

    I've only scratched the surface here, but suffice to say that "fixing" the American system will require a lot more change than anyone imagines.

    Education reform
    Tort reform
    Attitude reform
    Tax reform

    I doubt the rich are going to give up the cushy system they have in America, where their salary does not affect the cost of their insurance. This is the real issue that probably will foil any plans for health reform.

    "Why should I pay for others' healthcare?"

    -Mr. Rich Guy

    I'm sure No_Slappz is asking the same question.

    Especially since he views people's lack of insurance as purely their own fault.

    By Blogger Praguetwin, at 6:26 PM  

  • praguetwin, you wrote:

    "Getting to Dianne's point, it is the lack of recourse against doctors who make mistakes that helps keep costs down."

    I'm not suggesting that medical malpractice lawsuits are good. They do add to the cost of healthcare. But you reach a totally completely incorrect conclusion when you state:

    "The same is true if I fall in a hole on a public street."

    Not even close. A patient is not responsible for the errors of his doctor. A drunk falling on the sidewalk has contributed to his own misfortune.

    You wrote:

    "Accidents happen, and liability is contained."

    You simplistically think accidents are some form of random misfortune for which no one bears responsibility. Think again. That's not how things work in free economies. Believe what you want, but the Czech concept will NEVER arise in the US.

    In fact, responsibility for accidents falls somewhere, on someone or some thing. Malice may have no role in the accidents. Doctors want patients to live. But sometimes they make fatal mistakes. Cities want safe sidewalks, but sometimes the pavement buckles and people fall. Thus, in both cases, there is a culpable party.

    Here's the big number. New York City pays out about $500 million A YEAR in personal injury lawsuits.

    This is a truly unfortunate state of affairs. But until juries stop awarding substantial sums to injured parties, I don't know how things will change.

    You wrote:

    "However, other doctors will fix me free of charge should a doctor make a mistake, or if I fall in a hole."

    Even if you're dead? Or paralyzed or brain-damaged as a result?

    In the US, the only way to stop multi-million-dollar malpractice lawsuits is for health insurance companies to cease operations. However, if you think that it's possible to stop huge awards by handing healthcare funding to the federal government, think again. As every city and state government knows, Americans can and do fight "city hall", and they win.

    If the federal government were to administer healthcare for the entire US, the number of lawsuits and their total face value would soar from current levels.

    Since nothing would prevent doctors and insurers from remaining independent of the government, many doctors would choose private practice over government service. As in every aspect of government-vs-private activities, the less experienced and less competent practitioners would serve in the government program.

    As compassionate as they might be, you can be sure their professional record would include mistakes. Suits would follow. If, in your plan, awards were restricted or citizens were barred from suing, the result would very quickly lead to far more malpractice catastrophes occurring among the poor than among everyone else.

    From there you will have racial discrimination suits claiming that substandard doctors are treating the poor -- black -- patients.

    Similar suits regarding the public school systems are already working their way through the court system. New York City won a suit that claimed too few education dollars were awarded to NYC over a period of years. The sum awarded to NYC was $5 billion. Thus, the residents of NY state must cough up an additional $5 billion for the NY City school system. So the taxpayers pay twice.

    If you think there is a way to avoid similar fights over healthcare coverage, you are mistaken. Worse, the numbers will be higher.

    You wrote:

    "Getting to the education question, it is the tradition of education (not the amount spent) that supports the system. Until doctors can be trained for a reasonable amount of money, their fees will remain unreasonable."

    Oh. In other words, a guy who gets into Harvard Med school is a bad risk because he's going to pay top dollar for his medical education. In your view, then, going to Harvard Med School is a bad idea.

    Even if taxpayers wrote the tuition check to Harvard, the cost would not drop. The problem with medical school education is its intrinsic expense. It's real. Med schools are expensive to run. Unless you want students to keep it all theoretical and learn their medicine from reading books, it will take lots of bucks to educate them.

    The idea that it is somehow possible to teach medicine at WalMart rates is laughable. No matter how the bill is paid, the bill is large.

    You wrote:

    "I doubt the rich are going to give up the cushy system they have in America, where their salary does not affect the cost of their insurance. This is the real issue that probably will foil any plans for health reform."

    You are out of touch. While medical coverage is not set at a fixed portion of a person's salary, coverage costs vary over a wide range. A very wide range. Employees of corporations choose from various plans that fit their budgets. Unless they are teachers, cops, firemen and other state employees. Then, for ZERO out-of-pocket expenditures, those teachers, etc., enjoy GOLD-PLATED coverage that any CEO would envy.

    Meanwhile, if you are self-employed, well, then the percentage of income devoted to medical coverage is shockingly high for a good plan.

    Look. I think the American healthcare system needs many changes. But America is not going to change its character. Therefore, many facets of medical coverage are unchangeable.

    Meanwhile, if every smoker quit smoking, if every IV-drug user quit using, if every American drinker consumed small quantities of alcohol, if every American ate sensibly and if every American who knowingly engages in unsafe health practices improved his behavior, our national medical costs would drop enough to expand coverage without increasing the current expenditures.

    Of course we then become our own enemies. If we live longer through better health practices, the absolute numbers of people with Alzheimer's will skyrocket, raising expenditures in that way.

    By the way, what provisions do Czech's make for senior citizens with dementia? Nursing homes? Assisted living? Staying at home with the family?

    By Anonymous no_slappz, at 7:49 PM  

  • praguetwin, p.s.:

    Medical malpractice awards may represent the largest cost to New York State. Botched work by doctors working at municipal hospitals or other government settings have led to huge payouts from the state to injured parties.

    Of course, it's the taxpayers who get the bill.

    Analysis of the data shows that it is the high malpractice awards by the state that have contributed most to the high cost of healthcare. The major problem is NOT healthcare insurance companies.

    By Anonymous no_slappz, at 8:15 PM  

  • no-slappz,

    "In your own meandering way, you have said the government should cap the incomes of doctors."

    I said no such thing.

    "What is "preventive medicine"?"

    Trying looking it up. It's one of those things that involves extensive research. Basically, it involves seeking to stay healthy and having medical practioners (usually nurses or nurse practioners) help with that by using their extensive knowledge to advise in individual ways. Preventative medicines goes far beyond public health messages, by recognizing that people are unique individuals and treating them thus.

    An example, I have three sons with nutritional difficulties due to their developmental differences. For two of these sons, preventative medicine is enough. It involves brief visits with local nutritionists and consultation with a few developmental specialists. The cost is relatively cheap and it's easy to accomplish. However, for one of my children this was not enough. Due to his poor eating habits and developmental delays, compounded with sensory issues and health problems, he was not growing as he should and his long-term health was endangered. Preventative measures were taken first, but proved unsuccessful. Now, he goes to see a team of medical professionals that are highly specialized once a month in an effort to prevent him from being hospitalized. These measures also follow under the larger umbrella of "preventative medicine," because if this fails hospitalization, a feeding tube, and other drastic measures will be necessary (and legally obligatory).

    This is one example of prevenative medicine, but it is concerning children with special needs. Most times it is less dramatic. Measuring blood pressure regularly and working on life-style habits that keep it within healthy limits is "preventative medicine." It's also simple, and rather inexpensive. It can prevent long-term problems like heart-attacks and the expensive medical care that goes with it.

    "But the subtext of your comment boils down to state control of personal behavior."

    Hardly. It involves medical professionals working directly with individuals to meet their individual needs and offer advice tailored to the individual. The state could provide the means for this kind of care, but it would not provide the advice given, nor would it force individuals to comply with that advice. In the end, the deicision to act on the advice would be up to the individual, but the medical professionals would be able to offer advice that is tailored to the individual.

    "Or do you think we should ration healthcare to those who live sensibly?"

    Fittest survive, or something like that? That's not my style, though I find it telling that you would think of such a thing. The answer is in the very term: universal healthcare. You don't get to choose who is and who is not "worthy" of medical care.

    By Anonymous Stephanie, at 11:27 PM  

  • PT,

    "Until doctors can be trained for a reasonable amount of money, their fees will remain unreasonable."

    That is something that I was alluding to before. Whether no-slappz acknowledges it a lot, graduates from medical school pay quite a bit to get the education they do. Grants often don't cover half of the expense, and the expense of 8 (or more if you are a specialist) is quite expensive here. It can certainly be done in a manner that is more cost-effective without reducing the quality of the education.

    By Anonymous Stephanie, at 11:37 PM  

  • stephanie, I wrote:

    ""What is "preventive medicine"?"

    You responded:

    "Trying looking it up."

    Please. It's a joke. Anyway, in nearly all cases, your view of "preventive medicine" reduces to "clean living."

    But like I said, whether you will admit it or not, you want the healthcare industry or the government to stick its nose into the personal behavior of individuals. You want a nanny to tell people how to live.

    But it's pointless, because, as you say, a "universal healthcare system" covers everyone. Thus, the person who likes to drink, smoke, eat rich food and engage in dangerous sexual practices figures his government health program will patch him up every time his body revolts.

    Why would such a person change his behavior? Answer. He won't. Unless he has a mind-altering near-death experience. But even an event like that most often marks only a temporary lull in the action.

    When a service is more-or-less free, it is always grossly over-used. But that's not how to optimize its effectiveness. That only overworks the system.

    Sometimes people drive without car insurance. How often are they at fault in accidents? If they're sensible about it, they'll drive carefully to avoid tickets and accidents.

    Do people without health insurance attempt to limit their risks through "clean living"? Not as far as I can tell. What's worse is the behavior of those who are insured.

    Obesity is developing at crisis rates. An obese relative of mine recently had gastric by-pass surgery to stop himself from eating till he exploded.

    Preventive medicine -- a sensible diet -- didn't work. There will be many more of these operations performed on people who simply claim that diets don't work and demand to have their guts rerouted.

    Medical costs simply cannot do anything but skyrocket as long as the healthcare industry will develop treatments to satisfy every human health and body desire.

    Let me put this in perspective for you. There are prison inmates in the US who are demanding transgender surgery. The government is considering their requests.

    Clearly, there is no line drawn anywhere. You seem to think that's okay. But it will bankrupt the country.

    By Anonymous no_slappz, at 4:18 AM  

  • stephanie, you wrote:

    "graduates from medical school pay quite a bit to get the education they do."

    The price of a medical education has no bearing on the cost of healthcare. Foreign doctors come to the US unburdened by student loans. If the cost of med school were the culprit, the whole country would find itself served by doctors from other countries.

    You wrote:

    "Grants often don't cover half of the expense, and the expense of 8 (or more if you are a specialist) is quite expensive here."

    You are now arguing that you would prefer to get your doctors from the schools charging the lowest tuition without regard for quality. You would prefer a doctor from Cuba over a graduate of Harvard Medical School.

    You wrote:

    "It can certainly be done in a manner that is more cost-effective without reducing the quality of the education."

    Really? How? A medical school in the US requires land, special buildings, special facilities, and well trained instructors. Which of those do you think you can get for less than current rates?

    If you want to argue that the government -- the taxpayers -- should pay the tuition for med students, that only means that the same bills are distributed over many people. Just like the cost of caring for them, whether the revenue derives from insurance premiums or from revenue collected through taxation.

    Your idea does nothing to lower bills. It only shuffles around the payments. But the totals continue to move upward.

    Of course, with your generous universal plan, immigrants from all over the world will try to sneak into the country. Thus another boost for the bill.

    By Anonymous no_slappz, at 4:34 AM  

  • no_slappz sure does like to argue - doesn't he!! And as long as he thinks he's the only one right, and really isn't willing to listen .... see y'all later, I don't like to argue all that much. But Hey PT, thanks!

    By Anonymous Diane, at 5:09 AM  

  • no-slappz,

    "your view of "preventive medicine" reduces to "clean living"

    Clean living, as you put it, is only part of preventative medicine. Preventative medicine is several steps beyond 'clean living,' because it applies medical knowledge to problems that are both mundane and unusual. It is an individualized approach that treats people -- and their health -- as unique entities.

    From the aspect of 'clean living,' it gives people individualized tools to help them achieve their goals. For instance, trained medical professionals can help a motivated person quit smoking successfully by tailoring the manner of the smoking-cessation program to the individual's needs and difficulties. Most regular doctors and nurses do not have the time for such personalized intervention, and most insurance companies will not pay the doctors and nurses to take the time. Instead, people are told to quit smoking, given literature, maybe a medication to help -- and when it doesn't work, the individual feels like a failure, continues to smoke, and the long-term consequences in health and money are considerable. It doesn't have to be like that, but unless an individual has an extreme good health insurance plan (which costs a lot of money) or can pay for the expense out of pocket, they don't get the individualized attention that can turn several unsuccessful cessation attempts into successful, long-term smoke-free living.

    People turn to hypnosis and all sorts of tricks to try to stop, but such things are often no more than tricks. We have the science do better, but our health care system is not designed to employ individualized preventative methods and therefore cannot reap the long-term benefits such a program would afford.

    "you want the healthcare industry or the government to stick its nose into the personal behavior of individuals"

    Healthcare industry and government are not interchangeable in this discussion. You said government, I said healthcare industry. Muddying the issue will not make your position any more tenable.

    And, as far as the health care system goes, if you see a medical practioner they are already involved in your personal habits. They'll tell you to quit smoking, lose weight, eat more grains, or whatever it is you should do to take better care of yourself. However, they do not have the time, resources, or funding to give you the individualized attention that would assist you in the endeavor. Most doctors cannot even afford the time to explain in a convincing, personal manner why it would be beneficial. Instead, they rely on generic literature written for anyone and everyone.

    "Why would such a person change his behavior? Answer. He won't."

    People change. People change all the time. A person who does all the things changed to become the person who does all those things; the person was not born doing them. Some people need that revelatory experience, but many do not. Many need education, individualized attention. There are many programs of many different varieties that help people make successful changes. Some are government-funded programs, usually organized by the state or county or region. Some are non-profit programs, organized by caring medical professionals -- such as those who donate their time to measure people's blood pressure for free and to inform them what is good, what is bad, and how to help. Some of the most successful are available only to the wealthy, such as detox clinics, coaches, and the like.

    The piece-meal approach is often effective for those who it reaches, but a better organized approach could reach more people, have more breadth, and produce a healthier (and less expensive) population.

    "When a service is more-or-less free, it is always grossly over-used. But that's not how to optimize its effectiveness. That only overworks the system."

    Now, see, these are legitimate issues that can be worked out. That's part of the whole "equitable system" thing.

    For instance, my step-son's mother gets medical assistance for my step-son. Every time he has a cold, the sniffles, anything he goes to the doctor. He also has asthma, and despite going to the doctor every couple of weeks or so, it took us nearly seven years (and her mother losing her daycare liscence) for them to understand that they should not smoke in the house with him. They didn't even have to stop smoking; they just needed to stop smoking in the house. Within a few weeks his asthma attacks lessened; a few months later they were gone completely. A doctor who actually had the time to educate this (very ignorant) woman would have been able to prevent some of that hardship.

    "Sometimes people drive without car insurance. How often are they at fault in accidents?"

    You think uninsured motorists are more careful? On what do you base your opinion. Statistics don't seem to support that. I'd like to see you support your claim.

    "If they're sensible about it..."

    Actually, if they're 'sensible' they'll pay for the insurance, but hey, your concept of 'sense' is obviously different than mine. Paying for insurance is part of owning a car, if you cannot afford the one, you shouldn't have the other. It's called personal responsibility.

    "Preventive medicine -- a sensible diet -- didn't work."

    Preventative medicine and 'a sensible diet' are not synonymous. Preventative medicine goes beyond the simple recommendation of 'a sensible diet' to address issues before the become 'explosive.' You seem to steadily resist that concept. Really, you should do some research.

    "Medical costs simply cannot do anything but skyrocket as long as the healthcare industry will develop treatments to satisfy every human health and body desire."

    An equitable health care system wouldn't provide 'treatments to satisfy every human health and body desire.' Your assumption that is should is either ridiculous or an attempt to muddy the issue. Just because a treatment is available doesn't mean the price of all other treatments suddenly goes up. That's not the way it works.

    "The government is considering their requests."

    A equitable system would be designed to distinguish the frivolous from the necessary. Again, you're trying to muddy the issue. Your slippery slopes make for poor arguments.

    "You seem to think that's okay."

    No, you seem to think your can tell me what I think and that anyone but you would believe it.

    "You are now arguing that you would prefer to get your doctors from the schools charging the lowest tuition without regard for quality."

    No, I'm not. That argument has already been countered. If you're not going to read what people write, why do you bother blogging?

    "Which of those do you think you can get for less than current rates?"

    There are several states that have successful programs to provide quality medical training to a variety of medical professionals on the state's dime to compensate for their shortage of medical professionals. A similar program could be arranged in which costs are shared and lowered. Your elitist schools would still exist, but the quality, cost-effective training available at state universities would be more attractive to many would-be medical professionals -- as it already is.

    "Of course, with your generous universal plan, immigrants from all over the world will try to sneak into the country."

    Illegal immigration is a totally separate issue, and under an equitable plan they'd not be covered. Scare tactics are not any better 'support' than slippery slopes.

    By Anonymous Stephanie, at 6:40 AM  

  • NS,

    In a meandering way, you have almost understood what I was trying to say.

    Indeed, tort reform will have to be a large part of any system that wishes to contain costs.

    As to the hole, I wasn't talking about falling in a hole because I'm drunk, I was talking about falling in a hole because it was unmarked and the street poorly lit.

    Negligence on the part of the city? Sure. Liability? Not much. However, the injured does have free health care so there is some justice.

    By Blogger Praguetwin, at 10:24 AM  

  • Diane,

    Thanks,

    Yeah, it isn't so much arguing as a litany of absolute truths. I could pick through them if I had nothing else to do, but honestly, I just don't have the time or the will.

    Let him think he knows everything. He isn't going to change.

    By Blogger Praguetwin, at 10:25 AM  

  • Oh and one last point....

    Everyone should keep in mind that the Education system here is responsible not only for producing a surplus of doctors and nurses, but also for helping the economy outperform the others in the region.

    When people say "it all starts with eduction" the Czech Republic is living proof.

    By Blogger Praguetwin, at 10:26 AM  

  • stephanie, you really need a course in economics. Really. You are apparently among the crowd who believes that if the "government" pays for something -- like a medical education -- the expense is somehow removed from the national income statement.

    It isn't. Almost every statement in your post related to changes in the healthcare system that would add new layers of costs by way of increasing the number of people who perform tasks.

    You argued that doctors don't have time to inform patients about diet and other elementary facts of "clean living." You suggest that an army of dieticians should handle that task. Guess what? The doctors remain, still overworked, still well paid, and now the dieticians are added to the healthcare payrolls.

    You wrote:

    "An equitable health care system wouldn't provide 'treatments to satisfy every human health and body desire.'"

    But you want a Universal Healthcare Plan. You said the plan operators should have to accept everyone. No cherry-picking of potential patients. Your universal plan will include people who want a lot of wild stuff. The facts are in.

    You wrote:

    "Your assumption that is should is either ridiculous or an attempt to muddy the issue. Just because a treatment is available doesn't mean the price of all other treatments suddenly goes up. That's not the way it works."

    Again. You really need to learn some economics. You need to understand that concept of the "fungibility" of money. If prison inmates (who number around 2 million) need treatment for their illnesses, and AIDS is a common one, who pays the bills?

    If prisoners want sex-change operations, who gets the bill?

    But the most interesting part of your response was your claim that:

    "An equitable health care system wouldn't provide 'treatments to satisfy every human health and body desire."

    In other words, you have admitted that healthcare must be RATIONED. You have acknowledged that you believe some requests should be refused.

    With this admission, you have revealed that, in fact, you agree with everything I've said. What's more it means you don't believe your own utopian view.

    You have admitted that cost is the key issue. And you are willing to control costs by limiting service.

    I also like this quote from you:

    "Paying for insurance is part of owning a car, if you cannot afford the one, you shouldn't have the other. It's called personal responsibility."

    I see. But when it comes to one's life and health, you're ready to toss that concept into the wind.

    The social pathologies among the poor are crushing. But almost all are self-induced: smoking, drug abuse, alcohol abuse, violence.

    How does this square with your belief in "personal responsibility?"

    If drivers should only drive if they are insured because an uninsured driver may cause harm, why do you think millions of irresponsible citizens should have the right to dump their huge bills on the responsible members of society?

    Meanwhile, your idea that counseling people about health habits would lead to changes in personal behavior is pretty funny.

    Despite the inescapable facts about smoking, and the fact that warning labels have been on cigarette packs since 1964, there are still 50 million smokers in America. They consumer over 400 BILLION cigarettes a year.

    If 50 million people can fail to heed the smoking message, why will people heed other health warnings? They won't.

    You may claim that people change. Some do. But far too few. Only by force will high percentages of people stop smoking, drinking and drugging. But we are not a nation that will go that way.

    Writers of diet books and health gurus often make lots of money because hopeful people want to practice what they preach. Everything they advise is good. But obesity is increasing.

    Gastric by-pass operations work. Thus, millions of people want them. More doctors are performing them. You can be sure this procedure will achieve acceptance in medical plans. Its proponents will argue that a successful operation will improve the health of the patient and allow him/her to live more productively as a result.

    It is easy to argue that the cost/benefit of the operation is favorable. Thus, healthcare plans should cover it.

    Anyway, at some point you will see that our success in medicine is our curse. We can cure, repair, vaccinate, treat, improve, manage and care for patients with more and more conditions.

    Our ability to treat more and more medical problems will always cost more and more. And the more people who enter medicine, the more people who will devise treatments for the growing population. Thus, the total bill will increase at stunningly high rates.

    It cannot be any other way unless we change our national character by refusing to treat a growing list of maladies.

    Which problems do you think we should refuse to treat?

    By Anonymous no_slappz, at 3:20 PM  

  • PT,

    What kind of core curriculum does the Czech Republic have? I would be interested (long-term) to read your description of their system in a later post.

    By Anonymous Stephanie, at 10:24 PM  

  • The Czech education system is highly tracked. That is to say that people go to different schools starting at age 14 based on their interests and their abilities.

    Education is completely free all the way through University provided that the student passes the tests which include oral examinations.

    By Blogger Praguetwin, at 10:28 PM  

  • no-slappz,

    This is pointless. You do not read what I write, you do not think about what I write, you just assume you know what I think and know what I'm saying without paying any attention to what I'm actually saying.

    Please, learn how to have an intelligent discussion. You're obviously incapable of it at this point and will not be getting any further responses from me.

    If you feel the need to say another person said something they did not say, then perhaps you should reflect on the basis of your own arguments. Strawmen convince only the ignorant.

    By Anonymous Stephanie, at 10:29 PM  

  • PT,

    That's similar to what I have read about Soviet schools (though the study was based on information from the fifties and was pretty sketchy). Is the education level (as to what they actually learn) higher than the US, or comparable, as per actual skills attained?

    By Anonymous Stephanie, at 12:33 AM  

  • I would say the public schools give the students a much higher level of education on average, although in many cases it is very specific.

    The examination process is incredibly hard. You have never seen 18-year-olds so nervous as when they are preparing for finals. They actually have to stand in front of a panel and answer questions for an hour with no notes for each class.

    When they graduate, it is quite a big deal, and no easy task.

    By Blogger Praguetwin, at 8:26 AM  

  • The closest thing I've had to an oral examination is the two recorded speeches I had to give -- for speech class. They were terrible, but I still got my A.

    *sigh*

    The biggest thing I worry about, though, is the lack of either breadth or depth in the American education system. While my intelligence may be more than average, the fact that college is time-consuming without being intellectually challenging is worrisome. The fact that I get chided for asking questions that are "beyond the scope" of my classes is even more so.

    Ah, but it's convenient and it's supposed to mean something when I'm done.
    *shrugs*

    By Anonymous Stephanie, at 10:14 AM  

  • stephanie, you wrote:

    "You do not read what I write..."

    Oh, but I do.

    You wrote:

    "...you do not think about what I write..."

    Ah, but I do.

    You wrote:

    "...you just assume you know what I think and know what I'm saying without paying any attention to what I'm actually saying."

    Frankly, it's obvious that your grasp of matters is entirely superficial and that you have zero concept of the actual operations of vast systems.

    Like I said, you really need a course or two in economics.

    Meanwhile, your comments have a subtext. You cannot seem to understand that the subtext of your comments reveals much that contradicts your stated positions.

    You wrote:

    "If you feel the need to say another person said something they did not say, then perhaps you should reflect on the basis of your own arguments."

    On the contrary, you should examine your statements to understand why they express ideas contrary to what you think you are stating.

    By Anonymous no_slappz, at 5:31 PM  

  • praguetwin, you wrote:

    "Indeed, tort reform will have to be a large part of any system that wishes to contain costs."

    Well, here's the sad facts: Tort Reform -- limits on the amounts of punitive awards in lawsuits -- is an idea that seems to have lots of appeal. But legislators don't support it. The US population shows no real support for it either. Tort Reform is merely a political football that proves its utility at election time. But never at any other time.

    You wrote:

    "As to the hole, I wasn't talking about falling in a hole because I'm drunk, I was talking about falling in a hole because it was unmarked and the street poorly lit."

    In NY City personal-injury lawyers pay people to report the existence of pot-holes, damaged sidewalks and other similar hazards. Why? Because after NY City is notified of the existence of such hazards, it is then liable for subsequent injuries.

    That means if you damage your car by hitting a pot-hole in the road, the city is liable for repairs AND injuries, if the occupants are hurt.

    Okay, you don't like my drunk-falls-on-the-sidewalk scenario, even though people to win awards under those circumstances.

    Here's another. A couple years ago the Staten Island Ferry was approaching Staten Island. The captain had some kind of personal breakdown on this particular crossing. He slammed this huge ferry boat into the dock. The collision killed 11 people on the ferry and seriously injured 71 more. One young man lost both legs when the side of the ferry was ruptured by a piece of the dock cutting through the hull.

    How much should the injured parties have received?

    So far, the city has settled 33 suits for a total of about $2 million. But those were the easy ones. The guy who lost his legs isn't one of them. Meanwhile, a judge recently ruled that the City cannot use the law to put a cap on the settlements.

    I'm not sure about the "right" number for compensation in this case. But by any analysis the amputee has lost a lot, and he's young -- around 30, I believe. I don't want to burden the taxpayers, but this guy was seriously injured while riding a city-owned ship.

    The point comes back to the fact that in a free society, people can sue for damages. Without giving up freedom, I have no idea how this can change.

    You wrote:

    "Negligence on the part of the city? Sure. Liability? Not much."

    Negligence is the chief component of liability. If the city had not been negligent in its rules for ferry-boat operations, the accident would not have occurred. Anyone who reviews the events of this case will see that negligence was abounding. It's tough to see such blatant carelessness on the part of the city. But it happens.

    You wrote:

    "However, the injured does have free health care so there is some justice."

    I think you had better check the definition of "justice".

    A number of people lost limbs in the ferry boat crash. How in the world can you suggest that free medical care constitutes "justice"?

    As much as I accept that the US federal, state and local governments have important jobs to do, I do recognize that sometimes a few of the millions of people who work for the government make huge whopping mistakes.

    Police brutality does occur. There are times when I side with plaintiffs who were injured by overzealous cops in NYC. In any case, as I said, NY City pays out about $500 million a year to settle liability cases. And medical malpractice is the single largest source of liability problems. Once again, sometimes the cases are real heartbreakers.

    City doctors occasionally botch deliveries, causing massive brain-damage to new-borns. Juries are willing to give the mothers lots of money. What strategy can stop these payouts? Again, in a free economy, I don't know the answer.

    By Anonymous no_slappz, at 6:09 PM  

  • praguetwin, you wrote:

    "Everyone should keep in mind that the Education system here is responsible not only for producing a surplus of doctors and nurses..."

    Are you saying that there are so many doctors and nurses that some are out of work? Or are you saying that the taxpayers are forced to pay the excess doctors and nurses even though there is little or no work for them?

    You said:

    "...but also for helping the economy outperform the others in the region."

    Saying education is the source of prosperity is a truism. Meanwhile, after noting the unfortunate spelling error the following sentence, it appears you were not schooled in the Czech Republic.

    "When people say "it all starts with eduction" the Czech Republic is living proof."

    Sorry. Couldn't resist.

    By Anonymous no_slappz, at 6:25 PM  

  • praguetwin, the following article appeared in the Wall Street Journal today, July 10, 2007.

    The article addresses worker behavior and the fact that workers are leaving Eastern Europe for higher wages elsewhere. If Czech doctors speak other languages, they too are leaving for higher pay in other countries.

    The Article:

    HELP WANTED

    Shortage of Skilled Labor
    Pinches Eastern Europe
    As Workers Move West,
    Continent Is Losing
    Competitive Weapon

    By JOELLEN PERRY in Warsaw and STEPHEN POWER in Bratislava, Slovakia

    July 10, 2007; Page A1

    In recent years, global car makers have flocked to Slovakia, attracted by the Eastern European country's plentiful supply of cheap, skilled labor. But this year, when Kia Motors Corp. needed extra workers at its local car plant, it had to place fliers in local newspapers and mailboxes urging residents to apply.

    Near Bratislava, an area with so many car and supplier factories it's now known as Detroit East, rival Volkswagen AG is so short of help that every day it buses workers from as far away as 60 miles.


    "I have the most difficult job in the company," says Jaroslav Holecek, director of human resources at VW's Bratislava plant. "Every day people come to me and say, 'I quit. I'm moving to England.' We can't stop them."

    Fast growth and high emigration to richer Western European countries are threatening to undermine a crucial asset of the former Soviet bloc nations that joined the European Union three years ago: plentiful, skilled labor at the right price. A dwindling pool of workers is driving up wages in key industries and forcing companies to go to greater lengths to recruit and retain people. It's also eroding one of the EU's responses to competition from Asia -- its low-cost hinterland.

    Reform fatigue is compounding the problem. In formerly communist countries, the transition to free-market economies has brought more than a decade of belt-tightening and political turmoil. Across the region, workers are growing frustrated. Populist governments are capitalizing by trying to roll back earlier changes to labor laws and to block new ones.

    Well beyond Eastern Europe, global economic growth has been so strong for the past three years that unemployment rates have come down almost everywhere. The euro zone's unemployment rate fell to 7% in May, the lowest since Eurostat, the European statistical agency, began calculating the measure in 1993. The U.S. jobless rate in June was at 4.5%, close to a six-year low, though the pace of wage increases for typical workers hasn't accelerated much. The 30-member Organization for Economic Cooperation and Development said recently that in nearly two-thirds of its member countries, unemployment has fallen below sustainable rates.

    As the global economy strains against capacity constraints, central bankers are worrying about rising inflation rates -- a sharp contrast to the worries about deflation earlier in the decade. Companies in many countries are operating at close to full capacity, facing shortages of everything from land to equipment.


    The car, electronics and other companies operating in Eastern Europe aren't about to pull out. With average wages just 16% to 34% of those in countries such as Germany, the countries of Central and Eastern Europe could remain attractive places to make cars and other goods for years. But the labor squeeze is driving up costs, giving new leverage to workers, and speeding Eastern Europe's transition from a low-cost manufacturing haven to a mature market economy.

    "Our friends in Eastern Europe should have the same high living standards as people in Western Europe," says Carl-Peter Forster, president of General Motors Corp.'s European division. "The question is how fast you go....We should avoid adjusting the standards too quickly, in order not to lose many opportunities for job growth."

    In recent years, waves of foreign investment and booming domestic consumption have spurred growth across Central and Eastern Europe. Last year, tiny Slovakia raked in a record $4.2 billion in foreign investment. Poland, the East's biggest economy, attracted a record $13.9 billion. Last year, Slovakia's economy grew by more than 8%; Poland's, by 5.8%. The 13 countries that share the euro currency grew, on average, by 2.7%.

    Now, central banks across the region are fretting about wage inflation. If they respond by raising interest rates, economic expansion will likely slow as consumers and firms curtail spending. The National Bank of Poland cited rising wages as a reason for its surprise quarter-point interest-rate increase, to 4.5%, in late June. Multinational firms are unlikely to scratch already-planned projects, but economists worry that shortages of skilled labor could crimp future spending.

    "This may become a constraint to further foreign direct investment and economic growth," says Jan Rutkowski, a World Bank economist for Europe and Central Asia.

    Already, skills shortages are forcing companies to worry that worker turnover could affect quality.

    "It's much more challenging to keep the production lines running," says Nikolaus Pfister, general manager of SE Bordnetze-Slovakia in Nitra, Slovakia, which supplies wiring harnesses to car makers. In the past year, the company has doubled the number of supervisors on its factory floor. "We have new people pouring in every week," he says. "You have to check their work."

    Polish President Lech Kaczynski has complained of being unable to find someone to paint his house because all the painters have moved away. Since Poland joined the EU in 2004, some 800,000 Poles -- many of them young and educated -- have emigrated westward, by conservative estimates. Most go to the United Kingdom and Ireland, which lifted labor-market restrictions for eastern EU members. Last year, the exodus helped reduce Polish unemployment to 13.8%, from nearly 20% three years ago.

    Poland's unemployment rate is still among Europe's highest. In part, that's because many workers, trained in the communist era, have skills more suited to declining state industries like shipbuilding and mining. For others, housing shortages and higher prices keep them from moving to where the jobs are.

    Marek Stanistawek, a 63-year-old carpenter, lives in Radom, a once-booming industrial and textile center some 70 miles south of Warsaw. Although unemployment in Warsaw has dipped to 4%, Radom's rate exceeds 23%.

    On a recent morning, Mr. Stanistawek joined a throng of job seekers at Radom's unemployment office. He said he's been looking for a job since 1991, when the local telephone factory where he worked for 32 years shut down. He collects 200 Polish zloty a month -- about $70 -- in welfare payments, which helps to cover the 260 zloty rent on the apartment he shares with his daughter and 13-year-old granddaughter.

    Mr. Stanistawek said he knows there are jobs in Warsaw, but contends that the costly commute and higher prices for food and rent in the capital would take too big a bite out of his pay. "My family and friends are here in Radom, not in Warsaw," he says. "Even if I'm not working, it's better to be here."

    In other parts of Poland, investment surges have tightened competition for technology and back-office workers. Tax breaks and a surfeit of cheap, educated labor have lured companies to the region around Wroclaw, a city of 670,000 in western Poland, where Hewlett-Packard Co., Sweden's Electrolux and Korea's LG Group have set up shop in recent years. By last fall, the pool of skilled labor was so shallow that Mayor Rafal Dutkiewicz put up billboards in the U.K. and Ireland proclaiming: "Come back, Poles, we have work for you. Wroclaw loves you."

    Poland's labor laws also contribute to labor shortages. Teachers and coal miners, for example, can retire after 25 or 30 years of work, regardless of age. As a result, as many as 1.6 million able-bodied Poles -- 6.5% of the working-age population -- are not part of the labor force. Partly due to pressure from businesses, the Polish government pledged to curtail some early-retirement programs next year. But analysts worry law makers will bow to political pressure to preserve the perks.

    In Slovakia, car makers and other large employers have tangled with Prime Minister Robert Fico over government attempts to restrict their ability to hire temporary employees, and to set limits on the amount of overtime work that companies can demand from employees. Mr. Fico, a left-leaning populist, says it's time for ordinary Slovaks to reap the benefits of a fast-growing economy, starting with "a more social labor code."

    "I don't want companies to invest here because we have low wages," Mr. Fico said in an interview during a visit to Volkswagen's Bratislava factory. "I want them to invest here because we have highly qualified workers and good infrastructure."


    Shortages of skilled laborers have caused some employers to grant hefty pay increases. In April, Skoda Auto, Volkswagen's Czech unit, agreed to a 12.7% pay increase, phased in over 21 months, for some 25,000 workers after they staged a one-day strike. Last month, some 2,700 workers at a General Motors plant in southeastern Poland got $650 bonuses -- more than half an average month's wages. In addition, they got 1% wage increases this year and last.

    This year, wages in Poland are expected to grow faster than productivity for the first time, according to Warsaw's Center for Social and Economic Research. Polish doctors earn about $460 a month, prompting many to emigrate westward for higher salaries. Many of those who have stayed behind are now holding strikes, demanding pay increases of up to 100%.

    Employers are also concerned about Eastern Europe's aging work force. One quarter of Skoda's Czech workers are over 50 -- a percentage that's rising fast. Industry executives are lobbying Prague to speed the approval of work-permit applications from job seekers in former Soviet republics, as well as from countries with young populations, such as Vietnam.

    The scarcity of skilled workers is acute in the area many Slovaks refer to as "Detroit East," which extends in a roughly 120-mile radius around Bratislava. Car production in Slovakia is set to more than double this year, to more than half a million vehicles. As early as next year, Slovakia, with a population of 5.4 million people, could become the world's largest producer of cars per capita, according to estimates by J.D. Power Automotive Forecasting.

    Until a few years ago, foreign companies tended to shun the country -- Volkswagen was an exception -- amid concerns about its authoritarian premier, Vladimir Meciar. An ex-boxer, he tightly controlled the state media and drove up the deficit with public-works projects. Then a more business-friendly government took over, cutting corporate taxes and putting the country on track to EU membership.

    In January 2003, Slovakia bested Poland in a contest for a new €700 million, or $954 million, Peugeot factory employing more than 3,000. A year later, Kia decided to build its first European plant in Zilina, which is 120 miles northeast of Bratislava. That created more than 2,000 additional jobs directly and lured more suppliers to the region. Employers from other industries have followed, including Samsung Electronics Co., which in March announced plans to build a new factory in Trnava.

    "It's a totally different market," says Mr. Holecek, the VW personnel director. "We used to be alone here. People only wanted to work for VW."

    Now, car makers and suppliers in Slovakia are recruiting from farther away -- even from outside the country. Peugeot has built 1,400 dwellings at its factory in Trnava to lure more workers from the country's east. Volkswagen last year recruited about 100 workers from Poland, only to see most quit within a few months to take jobs in Western Europe, company officials say.

    "When we advertise, there's often no response," says Norbert Gabriel, director of a Brose AG factory in Bratislava that supplies Volkswagen with door systems and window regulators.

    The shortages have benefited workers such as Kamille Lenart, a 26-year-old Hungarian. In 2004, after two years at Edscha AG, a German auto-parts supplier in the western Slovak city of Velky Meder, she moved to Hungary for a job at Audi, increasing her monthly pay to about $950 from $680. This April, she jumped to Dirks Logistik GmbH, a Volkswagen contractor in Bratislava. "I was constantly getting offers and I didn't have to go far away to earn good money," she says.

    More than 170,000 Slovaks now work abroad, according to government estimates, nearly three times the number in 2000. Robert Tancibok, a 22-year-old welder at VW's Bratislava plant, recently told his bosses he plans to move to Frankfurt later this summer. He intends to wash dishes at a restaurant for about $11 an hour, about 30% more than his hourly wage at VW. He says he wants to earn enough money to one day return to Slovakia, buy his own house and start a family.

    As Eastern Europe's population ages, some economists contend, labor-supply problems may grow. Five of the eight ex-communist countries that joined the EU in 2004 had net population drops last year. The cost of caring for rapidly aging populations could drive up tax rates and deficits. That, in turn, could make it difficult for countries to embark on public-service projects such as building affordable housing to help lure emigrants back home.

    Already, some large employers in Eastern Europe are looking farther afield for solutions. Mr. Pfister, the executive at the wiring-harness maker, says his company has cut roughly 700 jobs in Slovakia over the past year -- 20% of its local work force -- and transferred some production to Ukraine, Bulgaria and Morocco.

    Others are importing labor. Poland's largest residential building firm, J.W. Construction, imported some 200 laborers from Uzbekistan and Tajikistan in April to supplement its Polish skilled-labor work force of 1,000. Last fall, to help construction and agriculture firms, the Polish government lifted visa and work-permit restrictions on short-term workers from neighboring countries such as Ukraine and Belarus. Proposals are afoot to extend those privileges to workers world-wide.

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