When I started this series, I planned for the bulk of the posts to be discussions of the health care systems in individual countries. I was sidetracked by a number of other issues, but I'm hoping to start mixing in some individual country posts. I figure France is a good place to start, since it was ranked #1 in the world by the WHO study. The Reid book tends to be a pretty good source book for facts [although I disagree strongly with what I consider its viewpoint]. Another good source for facts is The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World, by Michael D. Tanner of the Cato Foundation. I have found no real disagreements between the Reid book and the Cato report on matters of fact, although the Reid book omits mention of many of the problems described by the Cato report.
The basics of the French system:
- Everyone in France is required to belong to a health insurance fund. Which fund you're in is basically a function of your occupation. The largest fund covers about 83% of French residents. Premiums are funded through payroll taxes. Premiums, benefits, and provider reimbursement rates are all set by the government.
- The French system is the world's third most expensive as a percentage of GDP, at around 11%.
- You're generally free to see whatever doctor you want. Recently, there's been something of a move to using primary care physicians as gatekeepers for specialists, although this is more of a gentle nudge than a hard constraint.
- The system in theory is supported by payroll taxes [generally about 20% of income], but in practice, the system has been running large deficits for years.
- The average French doctor makes about $55,000 per year, less than half what a US doctor makes. On the other hand, French doctors do not pay for medical school, and their malpractice insurance is vastly cheaper.
Compared to many of the other systems we'll look at, the French system has substantial exposure to market mechanisms:
- Most services require substantial copayments [10-40%] at time of service. The percentage of health care paid out of pocket in France is about 13%, which is roughly the same as in the US. Compared to the US, the actual payments for the services do tend to be much lower. Additionally, extremely poor patients and patients with expensive chronic diseases end up being exempted from copays; in this regard, the system can be viewed as having "catastrophic illness" coverage built in.
- The French government sets reimbursement rates. It does not set what physicians are allowed to charge. About one-third of French doctors charge rates higher than the government reimburses; in Paris it's about 80%. [This is for private physicians; physicians employed by public hospitals can't bill more.]
- Because not all desired services are provided by the mandatory insurance, and because many doctors charge higher rates, approximately 92% of French citizens purchase supplemental private health insurance. Compared to the US, this private insurance market is relatively unregulated: the private plans can decide what benefits to offer, can exclude preexisting conditions, and there is no guaranteed issue.
On the whole, these market mechanisms help the French avoid many of the worst problems we'll see in other countries. On the other hand, there are certainly problems:
- Costs in France have been growing very rapidly. The system is viewed as being in financial crisis. The system is about 2/3 as expensive as in the United States, and it seems plausible that the only reason it's not more expensive is that the doctors are paid much less.
- Setting doctors salary by decree doesn't really work in the long term; in the last decade, there have been doctor strikes in France.
- At least some French experts view their own system as "unsustainable", and feel that private hospitals in the US have better incentives to provide high quality care.
- The US "fee for service" system has been criticized because it incentivizes hospitals and physicians to perform more procedures than are necessary. On the other hand, the French system of lump-sum payments to state-run hospitals is being phased out in favor of fee-for-service, in the hopes that this will make it easier for the government to track if the money is being spent efficiently.
- As is the case in many countries with national healthcare systems, there's been a lack of capital investment, and patients in the US now have much better access to MRI and CT scanners than in France. [This is actually the case in basically every country with national healthcare except Japan, which is very technology heavy in its approach.]
- A French government-commissioned 2004 report described the system as "badly regulated" and "badly governed", and at least partially blamed the deaths of 15,000 elderly French during a 2003 heatwave on the system.
- The French system has large inequalities in both access to care and health outcomes based on income and class [see the section "Inequalities in health"], likely because of differing abilities to afford supplemental private insurance. Note that the extremely poor who are not making co-pays will end up having to go to public hospitals rather than seeing private physicians. The average French person seems not to be aware of this, and Reid certainly doesn't mention it.
Overall, the French system is not a terrible one. It is arguably better than the system we have in the US right now, and [in my opinion] almost certainly better than what we're going to get after the provisions of the PPAC come into effect. The system has substantial exposure to market mechanisms, and while it is officially based on notions of equality and universal access, like the US, it is a two-tier system where the rich get better care and have better outcomes. The parts of the system that seem to be working best are the free market-based parts; the government controlled parts seem to be suffering from rapidly rising costs, occasional strikes, and lack of capital. It will be interesting to see how the French system evolves over the next decade.
As a final note, Reid has some fascinating quotes about his interactions with doctors. One doctor says that he manages to improve his small income slightly by "billing his Audi to the medical office, even when he uses the car for personal trips." [Reid, p. 61] When discussing a 2004 law that changed the copay for seeing a specialist without a GP referral from 30% to 40%, another doctor says that none of his patients pay this extra fee because he routinely certifies that there's a GP referral whether or not it's true. [p. 56] From his tone, Reid seems to be in favor or at least neutral on both of these behaviors, but from the point of view of the system, these are both what is generally referred to as corruption [see also "fraud, waste and abuse."] I personally find this absolutely fascinating as a direct example of how when government regulations restrict behavior, there is always a temptation to cheat. This is one of the costs of a regulation-heavy system, and it is one that is easy to underestimate.
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