5 Questions About French Health Care

by Tim Foley

category: Health Care Around the World

Published March 08, 2009 @ 09:53PM PT

Centuries of the Anglo-Franco rivalry and more recent disagreements on geopolitical questions may color the American perception of the French.  (Uh, you think?) But try this description of their health care preferences on for size:  they’re fiercely protective of their ability to choose whatever doctor they want and get whatever treatment they want – “rationing” is a dirty word.  So is “socialized medicine,” with the English and Canadian health care systems coming in for particular scorn.  And 92% of its citizens have some form of private insurance.

Surprised?

Well, suffice to say there are also marked differences.  For one, the French spend about half of what we do per person on health care.  For another, the French have an idea called solidarity – simply put, the sicker you are, the less you should pay.  Finally, the French provide health care coverage as a right due to all citizens, and do so with a quality rated first in the world by the WHO.

So let’s dig into the details as this weekend’s “policy corner” with 5 questions on the French health care system.

1.)    Does France have single-payer?

This is a surprisingly subtle question to answer.  I’m going to go with “yes,” but that only tells part of the story.

Employees and employers fund a payroll tax into Sécurité Sociale, the social safety net program which spends most of its money on health care.  Employers pay 13.55%, individuals pay 0.75%, and then there’s a 5.25% general income tax that goes to the cause as well.  All in all, it’s a tax on about 18% of a person’s income, although each individual is only paying 6% -- and yes, those who are unemployed and cannot get on their parent or spouse’s plan is floated by the government, as are those making less than 6,600 Euros a year.  There’s a main government plan, and a number of industry-specific plans.  Between them, 99% of the population is covered.

With that, the patient has access to any of the public hospitals (over 60%) and nearly any doctor – 97% of doctors in the country will accept Sécurité Sociale compensation.  You’re covered for everything at the public hospitals – primary care, emergency care, surgery, pharmaceuticals and especially pre-natal care through early childhood care – a level of coverage that makes France the model system for young mothers and mothers-to-be.  And yes, the doctors nearly all make house calls.

There are no deductibles in France, but there are co-pays, usually about 30% or less, similar to what we discussed for Japan and Switzerland.  In the majority of cases, the patient pays the whole fee at the time of treatment and is reimbursed for 70% by the government within 10 days.  But there’s never a concern that co-pays or total costs will bankrupt the patient because of “solidarity.”  Have diabetes, heart disease, cancer, another chronic disease, or particularly complicated surgery that requires a long hospital stay in recovery?   You pay nothing.

Sounds straightforward single-payer, yet there’s a flourishing private insurance industry.  This is for complimentary insurance.  Doctors in public hospitals will charge you the government-set rate, but any private doctor is free to charge whatever he or she wants.  They’ll accept public coverage, but you owe the difference between 70% of the standard rate and what your doctor is charging.  That’s where private insurance comes in, and it covers the rest of the cost or, if you’re using a public hospital doctor, the cost of your co-pay.  It’s also your ticket to private hospitals – those run for-profit or as part of a religious not-for-profit.  Private insurance is so popular that 92% of the French have it, usually through their employer.

Think about that for a second – the French are so far ahead of us in terms of coverage for all that they’ve nearly covered their people twice over.

But to answer the original question, all French citizens have single-payer, but most have "single-payer plus."  So the answer is yes...ish.

2.)    Does France regulate the private insurance industry as much as Switzerland or Japan?

They don’t even regulate them as much as we do!

Private insurance companies have a free hand in the marketplace.  The one requirement nationwide is guaranteed renewal.  Although some consider this proof of the superiority of market-based solutions if left alone from government interference, the why is pretty obvious – you don’t need them.  Your health is not dependent on insurance, since public coverage in public hospitals takes care of most of your needs.   There’s no incentive for insurance companies to cherry pick, either, since government will pick up all of the tab for the most expensive customers.  The consumer has the power and freedom to take ‘em or leave ‘em.

Finally, because France has a uniform system for processing claims, the insurance industry has no excuse for administrative waste – they just use the uniform standards for records and claims processing.  As such, France has the lowest administrative costs in the world – 1.9% of all health expenditures according to the Commonwealth Fund National Scorecard (the same scorecard found the U.S. was at 7.3%, by far the most.)

3.)    What does France think about “socialized medicine”?

According to historian Paul Dutton, “The French don't consider their system socialized. In fact, they detest socialized medicine. For the French, that's the British, that's the Canadians. It's not the French system."

For the French, it’s not about how their universal health care is funded but how it’s distributed.  Although the public hospitals are funded with public money and there is some government oversight for correct management of the funds, they’re run independently – much like the public hospitals here in the U.S.  The doctors are not government employees, especially the médecin non conventionné, the private doctors who are allowed to charge whatever they want for their services.

Nor does the government tell them how to treat their patients. L’Agence Nationale d'Accréditation et d'Evaluation en Santé is the government board that conducts comparative effectiveness research, but it issues them as recommendations, not dictums.  Doctors must prove that they’re up-to-date on the latest treatment information in contracts both for Sécurité Sociale and private insurance.  Wouldn’t you know it, access to the latest information on treatment effectiveness tends to make you a better doctor!  The Ministry of Health has a board of doctors who determine what treatments should be reimbursable under Sécurité Sociale.  As you might suspect, they’re pretty open to all treatments with any medical value whatsoever, including homeopathic and alternative medicine.

Because doctors are so clearly the bosses of determining treatments and setting their own price, they’re not very likely to denounce the arrangement as socialized medicine or use government bureaucrats as scapegoats.  France is also helped by one factor not shared with the U.S. – the highest percentage of its physician force being primary care generalists.  Between that and the large availability of hospitals, wait times are almost unheard of.

4.)    How successful is France at controlling costs?

Compared to the rest of Europe, France is one of the most expensive health care systems.  Compared to the rest of the world, they’re the third or fourth most expensive health care system.  But as a sign of how ludicrous costs are in the U.S., we paid $6,401 per person in 2005, but France paid $3,374.  France is now a little more than $3,500, while we’re over $8,000 according to the latest figures from the Centers for Medicare and Medicaid.

Some of this can be chalked up to cultural factors, of course.  France notoriously has a higher percentage of the population that smokes (although compared to the rest of Europe, they’re actually not too bad.)  But their obesity rate is a shocking 1/3 of ours (9.5% of the population, compared to our 32.2%).  The croissant and éclair may be easy targets, but the Big Mac and potato chips are far worse for our health.  No doubt, a big part of America’s runaway health care costs is the rate at which more and more of us are overweight or obese.

The Ministry of Health sets prices for every service in a public hospital.  As mentioned, private hospitals and doctors are free to charge whatever they’d like, but the public hospitals have such market share that doctors are reluctant to get substantially higher on their fees.  How cheap are the prices?  Let’s try a general practitioner’s office visit – a service we’d expect to pay $150 for in the United States, at least.  In France, it’s about $28, of which the patient’s share is a little less than $8.50

We begin to see the same phenomenon we saw with Japan: when it’s cheap to go to your primary care doctor, you do - and you’re healthier as a result.  When the populace is healthier, and more problems are caught and treated early, when its cheap to do so, the costs go down.

Not that government cost-setting has worked perfectly, mind you.  Doctors in France are paid 1/3 to 1/5 of what doctors in the U.S. are.  This is balanced by medical school being free in France, so instead of entering the workforce with an average of $150,000 in debt, French doctors have $0.  Additionally, the French pay far less for malpractice insurance, and it has nothing to do with a damages cap.  Instead, Sécurité Sociale has a number of compensation procedures to resolve conflicts, meaning lawsuits aren’t the default option.  Still, striking French doctors protesting low pay have taken to the streets a number of times over the past few years.

Even more troubling, the national health care has been running a multi-billion dollar deficit for the last few years.  Costs are accelerating in France as well, driven by an appetite for new drugs and treatment by doctors and patients and an aging population.  Additionally, some physicians have begun gaming the system – ordering unnecessary tests to help up their low compensation.  To try to stem the tide, France has put new regulations into play, including adopting the “gatekeeper” approach of managed care in the United States.  You now need to appoint a general practitioner as your primary care provider.  If you see a specialist not referred by your GP, you pay more of the costs.

Yet, I must remind you again – they pay less than half of what we do.  This is a pretty good problem to have.

5.)    OK, so why does France rank first in the world for quality of health care?

The numbers speak for themselves – so much so that even Business Week took notice:

France's infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S.

The old fear of “moral hazard” – that people will abuse the system by using more health care if they pay less for it – proves to be misplaced.  People using more primary care is a good thing economically - it brings the costs down for everyone.  People not having access to primary care causes them to wait and wait and wait until their ailment is far worse and far more expensive to treat, and so brings the costs up for everyone.  The French offer a comprehensive benefits package – “as good as members of Congress get,” we might say – to every citizen.  Regular access to a primary care doctor – heck, even to the point of getting house calls – makes you healthier.  It’s not rocket science.

The fact that so often Americans who are uninsured and underinsured use the emergency room for preventable illness underscores another innovation of the French – one that saves them a tremendous amount of money.  The French system of emergency medicine is entirely unlike ours, as this video from CBS’ Morning Show demonstrates.   With a triage call system staffed not by hourly-wage dispatchers but actual doctors who can determine what is an emergency and what is not, to ambulances filled with doctors, nurses and support staff to treat you on the spot, rather than paramedics who can only stabilize you and get you to the nearest emergency room, the goal is to pre-empt a stay in the hospital, if it can be avoided.  Even with the extra physician staff, that’s a huge money-saver in the long run, since emergency care in the U.S. is the most expensive care you can get.

At the end of the day, we want a system that makes us healthier at a reasonable price and extends its benefits to all.  French polls say that 65% of the population is happy with their health care, and they spend 11% of their GDP on it.  In the U.S., we spend 16% but only 40% are happy with our health care.  It’s time to lay the caricatures aside and learn from the best.

(Photo credit:  stephenvawel on Flickr.)