What is health care like in France?


Here it comes. How dare I suggest the US could learn anything from France? By most assessments France provides the best health care in the world, with excellent life expectancy, low rates of health-care amenable disease, and again, despite providing excellent universal care, they spend less per capita than the US. Using about 10.7% of GDP and about 2000USD less per capita than the US they are providing the best health care in the world. To top it off, France's system isn't even socialized. That's right. It's yet another system that is a mixture of public and private funding that, if anything, provides the greatest level of physician and patient autonomy in making health care decisions. It is not, I repeat, not a single payer system. Doctors are largely self-employed, there is no big government authority telling doctors and patients what to do, just a progressive tax structure and requirements to pay into the system that fully subsidizes a functional healthcare system.

Start with the Wikipedia entry, if you can stand to read it try the WHO document on the structure of the French system, or various articles which all seem to agree the French system rocks. The few criticisms stem from it's relative cost compared to the other European systems and perhaps overutilization by citizens. But no one asserts that it provides poor care, that it rations care, that it limits doctor or patient autonomy, or has poor resources.

As with most health care systems, the more you read about it the more you see how the system reflects the values of the country. But these should be universal values.

Starting with free medical education, virtually no need for excessive administrative staff to deal with paper, full physician autonomy and a non-existent medical tort system, France sounds like an ideal place to practice medicine, but you do get paid less. The French system is universal, has public and private elements, and doctors enjoy great autonomy without interference from a centralized health system looking over their shoulders. The poor are covered, but those who work all have to pay into the system proportionate with income. Further, it's bolstered by a separate schedule of progressive taxes so much of it is subsidized by the wealthier citizens. The public system pays the majority of medical expenses but the overwhelming majority of French citizens opt for private coverage to make up the difference. If one can not afford the private coverage and one gets sick, the coverage expands to 100% of your costs, so debilitating illness and loss of income don't mean people go bankrupt to pay their medical bills. The main criticism seems to come from those that aren't indigent enough to qualify for additional benefit, but not wealthy enough to buy into additional health insurance to cover the copayments, may fall into a limbo, but seems to be a small minority of the population.

It's by far the most egalitarian system out there, so it's not surprising that it provides the best health according to WHO rankings, outcomes like life-expectancy, infant mortality, mortality from health care amenable disease, surveys of patient satisfaction . Unlike the British NHS and the Canadian health service, universality is balanced with significant patient autonomy, the system allows one to pay for more coverage if desired, and one may chose one's own physicians and hospitals. Finally, there is no rationing, no wait times, no limits on care. People get the care they need, and it's not restricted by government guidelines but rather solely by physician recommendation. If a doctor prescribes a treatment, it's paid for.

This brings us to a question about the US system. Why is it so expensive? How is it that we still end up spending so much, when a system like the French one, universally accepted as superior in outcomes, service, and quality, manages to spend so little?

More like this

The U.S. system spends large amounts of resource trying to not provide health care.

By Jim Ramsey (not verified) on 28 May 2009 #permalink

It is also worth noting that the British system has a horrible reputation in France - waiting lists and British patients going to France to get surgery done.

The French system is complicated, due to the mix of public and private insurance and public and private health providers. To illustrate: if you work as a university professor in France, you are a civil servant... thus, paradoxically, your public health care mandatory coverage is subcontracted to a private nonprofit insurance company. This company may also cover you for non-mandatory coverage, but then you have to pay extra fees. This private insurance pays bills to public hospitals. But sometimes, even in public hospitals, physicians act as private practicioners. In private nonprofit hospitals, it is possible that the patient has to pay the hospital, the surgeon and the anaesthesist separately and under difference insurance rules.

This is really, really a far cry from a single-payer, single-employer system such as the British NHS.

Actually our system still has its faults, and is a fully political subject, the right in France being by tradition the party of a fraction of doctors (and therefore much influenced by the lobby of the wealthiest doctors).

The compulsory level of private insurance (« Sécurité sociale », « Sécu » in colloquial vernacular) is actually a mess of organisms which turns out to work quite well, except that you have to change centers when you change work. This was created in 1946 and is due to Communist influence (the Socialists would have preferred a unique organization for the whole country, the Communists put it in union's hands -- including bosses' unions). This is probably not broken, so there is no need to fix it. But it actually refunds less and less of healthcare (the most recent changes being about dental and optics healthcares, which is a shame, and removing homeopathy, which is good).

The countryside and the suburbs are medical deserts (I'm talking about whole départements), especially considering specialist doctors (I vaguely remember there being all of three cardiologists for the whole of Seine Saint-Denis, which stands 7th in population with 1.5 million). On the contrary, the Riviera (kind of like Florida, a giant retirement house) and Paris are full of doctors; as Paris has lots of rich inhabitants, those doctors often charge a lot of extra. Fortunately for the not-so-rich, the municipality of Paris has set up (I don't know when, this could be very old) some health centers which work quite well (and in my mind should be a model for the whole country).

The system runs with a chronic deficit; according to the right, this is because of poor people who go too often to the doctor, so they recently invented a (small) tax payable on each consultation and forbade private insurance to refund it. Given that the poor are more ill than the rich, this does not help illness prevention...
According to the left this is because the liberal doctors are paid per capita (which is an incentive to see their patients often). Another point for the health centers, I guess.

The hospitals lack doctors (they employ foreign doctors instead and pay them a third of the French doctors' wages). This is a shame considering that the demography of doctors is totally under public control (there is a selective examination with numerus clausus in the first year of medical studies). There is right now an ongoing reform of hospitals that has the doctors, nurses and staffs in arms against it.

An excellent point on the contrary is the CMU (« Couverture Maladie Universelle ») which was set up by the last Socialist government and is the truly universal minimum healthcare, that allows poor people to consult without paying (the insurance directly pays the doctor). This has done a lot for basic prevention in the poorer people; however, there are a lot of doctors who won't see patients under CMU (even though this is illegal, it is not actively prosecuted by the right).

Another black point is that medical studies are long and quite expensive, and a way of elite reproduction (of course much less ridiculously so than in the US). Some Régions (all of them save one are on the left right now...) which lack doctors set up a scolarship program in exchange for a pledge of working in the said Région for some years. This is an excellent idea that should be enlarged at the national level; this actually was a Socialist proposal during the last presidential campaign (and the Centrists also took it).

By Jérôme ^ (not verified) on 28 May 2009 #permalink

After reading this series of articles, I am surprised to see that the United States spend so much more than everyone else, and yet we still get less.

I will forever refuse getting an out of pocket medical insurance coverage if part of a healthcare bill not employer paid and sponsored, when seeing my regular medical check up bill was less when I was unemployed and paid cash vs when I had a high deductible and co-pay temp job cheap as insurance. It's all padded to pay worthless insurance admin monkeys to file extra paperwork that is for the insurance companies profit not anything hospitals or doctors require.

The whole thing about the wealthy subsidising the healthcare system? That's why this would never be accepted in the States. In the US, taxpayers are subsidising the system anyway, but it is hidden enough that they are not aware of the true costs; if the tax issue were up front, then you would have the knee-jerk wave of revulsion of "I'm not paying for a bunch of lazy, out-of-work bums to get medical care! It's money *I* work for, why should it pay for other people!"

It's a relatively shallow way of thinking based on lack of analysis of knock-on effects and costs, and the inability to follow any long chain of causation, but that's pretty much the way American politics runs.

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