by Jenny Kakasuleff of the Liberal Examiner
August 8, 2009
According to the American Journal of Public Health, “In France, the commitment to universal coverage is accepted by the principal political parties and justified on grounds of solidarity – the notion that there should be mutual aid and cooperation between the sick and the well, the active and the inactive, and that health insurance should be financed on the basis of ability to pay, not actuarial risk.”
In the United States, our system is the exact opposite. If you get sick in America, there are people who will search your medical records in search of a reason to deny you coverage – sometimes retroactively. In America, insurers rely on the premiums of their healthy customers to subsidize their profits and advertising costs, as well as the administrative burdens behind their intense denials of care – indeed, we all pay more, so that the profit sector is able to withhold, delay, or deny payment in order to satisfy shareholder demands. The system is designed to deny care to those who need it the most, which is an inherent failure that the free market cannot, or will not address on its own.
The French system lends valuable insight into our own, since it better integrates private insurance with a universal health care system.
France
The frequently cited study by the World Health Organization that compared industrialized nations on the basis of health care, ranked France number one; in contrast, the US held the title of 37th. Another study that focused on 19 industrialized nations by determining an “amenable mortality,” or the number of deaths that could have been prevented through quality health care, also ranked France first, and the U.S. last.
According to Business Week, the infant mortality rate in France is 3.9 per 1000 compared to 7 in the U.S. The life expectancy in France is two years greater than in the U.S. The French have more hospitals and doctors per capita, and much lower rates of diabetes, heart disease, and preventable deaths (31 in France compared to 61 in the U.S.). In addition to better health outcomes, there is no perception that health care is rationed; the French have no gatekeepers and are free to choose any doctor, and see any specialist they want. Physicians are free to provide any care that they deem medically necessary.
The French system offers extraordinarily comprehensive prenatal and early childhood care. In France, mothers and their children receive basic preventive care through a network of community-based health care facilities called Protection Maternelle et Infantile. Children are cared for by a team of pediatricians, nurses, midwives, psychologists, and social workers, and if a parent neglects to take their children in for regular checkups, a social worker will visit the family at home. Expectant mothers receive monetary rewards for attending their pre– and post-natal visits. Child care is also subsidized and affordable for working parents. As Daniel J. Pedersen, president of the Buffett Early Childhood Fund, notes “It’s based on the practical idea that high-quality investments made at the start of a child’s life will pay huge dividends to both the child and society in the future.”
According to the AJPH, national health insurance (NHI) “forms an integral part of France’s social security system, which is typically depicted—following an agrarian metaphor—as a set of 3 sprouting branches: (1) pensions, (2) family allowances, and (3) health insurance and workplace accident coverage.” The first two are managed by a single national fund, while the third is run by three main NHI funds: those for salaried workers, farmers and agricultural workers, and the independent professions. In addition, there are 11 smaller funds for workers in specific occupations and their dependents.
All of the plans are private, but operate within a standard framework and are heavily regulated by the government. They operate through a network of local and regional funds that handle reimbursement to health care providers, monitor for fraud and abuse, and provide customer services for their insured.
Health insurance is compulsory, enrollment is automatic based on occupational status, and the funds are not allowed to compete with each other by lowering premiums or denying coverage. The health care system in France is composed primarily of private practice operations for ambulatory care, and public hospitals for acute institutional care. Another distinguishing feature noted by the AJPH is its proprietary hospital sector – the largest in Europe – and which is accessible to all insured persons.
Basic coverage includes services including hospital care, outpatient services, prescription drugs (including homeopathic products), thermal cures in spas, nursing home care, cash benefits, and to a lesser extent, dental and vision care.
Physicians in ambulatory care are paid directly by patients, who are then reimbursed a fee that is negotiated through the funds, trade unions, employers, and provider associations. For inpatient hospital services, there are annual global budgets negotiated every year between hospitals, regional agencies, and the Ministry of Health, as well as per diem reimbursements. Prices for prescription drugs are set by a commission that includes representatives from the Ministries of Health, Finance, and Industry.
The NHI typically covers about 70 percent of health care costs. There are no deductibles, but moderate co-pays. In addition, more than 90 percent of the population subscribes to supplementary health insurance to cover these costs, as well as other benefits not covered under NHI. Chronic diseases and other critical ailments are reimbursed in full and cancer patients are treated for free. As mentioned above, in France, the more care you need, the less you pay.
In order to achieve such laudable results, the French pay more in taxes than Americans – about 21 percent of their income (employers pay half of that) – but they also receive far more for the tax dollars they pay. Beyond taxation, France has held down costs by negotiating far lower rates with physicians than their American counterparts receive – they earn about one-third of what US physicians do; about $55,000 per year. However, as Business Week points out, French doctors’ medical school is paid for by the state, malpractice premiums are a fraction of what they are in the U.S., and the government pays two-thirds of the social security tax for most physicians – a tax equivalent to 40 percent of income.
Nonetheless, cutting physician reimbursement rates does not reduce the demand for care, and is not a sustainable method of reducing costs over the long-term. Compared to its European counterparts, France’s health care costs are relatively high at 10.7 percent of GDP – though they are still much lower than the 16 percent we spend in the U.S.
Physicians manage to earn more by increasing their patient load, or by ordering unnecessary procedures – a problem common in the U.S. as well. The French system has been running deficits since 1985, which in 2007, was $9 billion. Officials are considering implementing health maintenance organization techniques in order to more effectively contain costs. For example, patients are now required to register with a general practitioner before visiting a specialist, or otherwise receive less reimbursement – similar to the U.S.
Nonetheless, 65 percent of citizens express satisfaction with the system, compared with just 40 percent in the U.S. As the AJPH notes, “It is the outcome of sociopolitical struggles and clashes among trade unions, employers, physicians associations, and the state.” Successes were not achieved overnight – neither was universal care. It occurred incrementally, in successive stages that progressively brought more individuals into the fold – and operates very similarly to Medicare. The indemnity model encourages patients to be vigilant of their care, while remaining conscientious of their consumption.
France offers a model of publicly and privately administered and delivered health care that reflects the type of system that could emerge in the U.S., but the government must ensure that reform includes the appropriate incentives and oversight to maximize efficiency.
The next article will explore Switzerland’s health care system.
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*If you would like to submit a health care story, with the possibility of seeing it published here, please send me an email message at jennyk1981@gmail.com.
