I got a letter from my health insurer in the States telling me they noticed (it probably popped up in a computer scan) that I hadn't had a stool blood test in a good long time (I have had negative colonoscopies so I personally don't see the point).  As I understand the research these tests cause more trouble from false positives and regularly miss many problems anyway and so in sum are of little value and a lot of hassle for the patient (although of course not nearly as much hassle as a colonoscopy).

So I ask myself what is going on.  Rarely will this particular insurance company pay for a test unless there is a clear standard calling for it, and then they only do the very minimum found in the standard.  In short, I am skeptical here, and the answer is pretty easy to infer -- they don't want to do colonoscopies and negative results on these stool exams gives them a legal excuse for not doing the more rigorous and much more accurate real exam in case a cancer and ensuing lawsuit takes place.

Health services in the States are so outrageously expensive that no sane person goes without insurance.  Still, it practically guarantees that I have no right to use my own judgement about treatment -- that the underwriters or claims managers can decide to refuse treatment if it is not in the "standard," even if the doctor and everyone else thinks otherwise, and they have a strong vested interested to behave in this way even if the patient is going to die as a result.

I guess it's a balancing act since there no doubt are many who would milk the insurance company dry -- both patients and doctors -- if they don't behave this way.  Still, I don't like it one bit and think both the high cost of health care in the States and this quandary are both brought about by the very institution of insurance.  People don't shop so insurance companies have to, and laws get passed by the doctors restricting their ability to do so, and legislators agree for obvious public interest reasons, so there is little if any competition holding down costs.  The system is a huge monopoly, aided and abetted  -- or maybe "amplified" is a better word -- by the malpractice legal system.

In Vietnam if some treatment goes wrong, you are not going to be able to sue your doctor, even if he makes some egregious mistake (there are criminal consequences though that has a considerable influence).  Further, while you can buy insurance, the cost of health care is so reasonable that you don't, but this does lead to your shopping around a bit and asking certain questions an American doctor never hears.  It's a "pay cash in advance" system, which also neatly deals with the bad debt problem so many hospitals in the States seem to have.

That would not work in the States because the charges are so high it would create serious social equity and moral questions.  In a society where the bureaucrats keep tabs on medical (and pretty much all other costs) and where there is effective competition anyway, you end up with better care at less cost and to my mind a grossly superior system.  (I leave out describing the details of the system, except to say it seems rationally designed rather than to have grown up mainly in the interests of the doctors and hospitals and now the insurers).

The problem one might think the Vietnamese have is what about the truly indigent.  Are they just to die?  Well, it doesn't seem to happen when costs are in bounds.  Charitable impulses from family and neighbors and religious groups and organized charities can far better manage the issue.  You may have a huge ward for your bed and things may not be as pretty and hospital-looking, but the care is what matters, not the esthetics.

The Buddhist maxim about dealing with the world is to be "wise" compassionate.  In other words, don't be naive, even though one is non-judgmental and forgiving and always as helpful as possible.  Such wisdom in my mind includes looking at systems to see where the incentives are.  Most people manage to rationalize their behavior to meet what is best for them, and this creates a fairly good system in Vietnam and one that is not so good in the States.