Drawn From


Differential Diagnoses

A Comparative History of Health Care Problems and Solutions in the United States and France


by Paul V. Dutton



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1) The World Health Organization survey.  In the largest ever study of its kind, the World Health Organization rated France's health care system as the best in the world in 2001 because of its universal coverage, responsive health care providers, patient and provider freedoms, and the health and longevity of the country's population.   The United States ranked thirty-seventh.  The U.S. score suffered because of the astronomical cost of U.S. health care, health disparities, and its well-known problems for those without insurance (15.9 percent of the population or 46.6 million individuals in 2005). 


2) Patient Choice and Access.  The vast majority of ambulatory care physicians in France are in private practice and patients enjoy extraordinary freedom of choice among them.  Virtually all primary care providers and specialists participate in the nation's public health insurance system, Sécurité Sociale.  A patient presents a single microchip enhanced Sécurité Sociale card at her physician's office, which permits the doctor on-line access to the patient's medical chart.  The patient is responsible for paying physician fees, however, the same card authorizes almost immediate electronic funds reimbursement from Sécurité Sociale to the patient's bank account.  In contrast to Canada and Great Britain, there are no waiting lists in France for elective procedures and patients need not seek pre-authorizations from Sécurité Sociale for procedures.  Acute care in France is dominated by public community and university hospital medical centers.  Yet France also possesses the largest private hospital sector in Europe, accounting for 36 percent of all beds.  The choice of hospital is up to the patient, his or her Sécurité Sociale coverage being the same in both the private and public sectors.   


3) Practitioner Freedoms and Pay.  French physicians remain firmly attached to fee-for-service medicine and possess broad freedoms of diagnosis and therapy, reminiscent of those enjoyed by American doctors prior to the advent of managed care.  However, the average American physician earns over five times the average U.S. wage while the average French physician makes only about two times the average earnings of his or her compatriots.  The relatively low income of French physicians is somewhat allayed by two factors.  Practice liability is greatly diminished by a tort-adverse legal system and medical schools, although extremely competitive to enter, are tuition-free.  Thus, French physicians enter their careers with little if any debt and pay much lower malpractice insurance premiums.


4) Price Comparison.  Like in the United States, French workers and employers split the cost of health insurance on payday.  Employees pay a one percent wage levy as well as a "social contribution" that varies according to income.  Employers pay a straight 13 percent wage levy.  Simple comparisons of insurance premiums in the United States are difficult because the price of American insurance depends on the "risk class" and size of the group seeking coverage.  A typical large American employer pays approximately fifteen thousand dollars per year for a family Blue Cross-Blue Shield PPO plan.  For a moderate-income earner (50 thousand dollars), therefore, health insurance cost, as a proportion of wages, are substantially higher in the United States--30 percent, versus approximately 20 percent in France.  The price of comparable coverage for a small firm is substantially higher in the United States.  France's health care system is among the most expensive in Europe: 10.5 percent of GDP, or $3,048 per capita in 2003.  However, this price tag pales beside the American: 15 percent of GDP, or $5,711 per capita in 2003, a cost that is expected to reach 18.7 percent of GDP by 2014.


5) Historical Development.  Universal coverage in France can be traced to the country's first compulsory health insurance law passed in 1930.  It mandated that industrial employers split health insurance premiums with their workers.  During the next ten years the law was expanded to about 25 percent of the population.  The present system (Sécurité Sociale) was born after the Second World War in 1945, and reached 99 percent of the population by the mid 1960s; France only achieved universal coverage in 2000.  Since its inception in 1930, compulsory health insurance in France has been based on two grand bargains, the first with doctors, and a second with insurers.  Doctors only agreed to participate in compulsory health insurance if the law protected a patient's choice of practitioner and guaranteed physicians' control over medical decision making, i.e., freedom of diagnosis, therapy, and prescription.  (The French medical profession's decision thus stands in stark contrast to AMA's fierce opposition to publicly mandated health insurance.)  Meanwhile, insurers also compromised on compulsory health insurance when legislators agreed to permit them to administer the new public insurance funds.  Although displaced by the birth of Sécurité Sociale after 1945, private health insurers (both for-profit and not-for-profit) were again accommodated, this time as supplemental insurers who provide coverage for expenses not paid for by Sécurité Sociale.  Indeed, nearly 90 percent of the French population possesses such coverage, making France home to a booming (and competitive) private health insurance market.


6) Present Dilemmas and a Prescription for Change.  Like in the United States, France's achievements are imperiled by health care inflation, especially as its population ages and requires more and increasingly expensive medical care.  Despite the substantial differences between French and U.S. health care, both are handicapped by their ties to the workplace.  In France, high Sécurité Sociale payroll taxes hamper efforts to decrease the country's persistent high unemployment rate because employers are reticent to hire unless certain that a new employee's added productivity will translate into sufficiently higher and enduring firm revenues to justify the commitment.  Moreover, French unions, which enjoy significant influence over Sécurité Sociale because of its payroll financing, have emerged as an obstacle to efficiency and cost control reforms.  Meanwhile, the United States has developed a different but equally serious labor-market sclerosis due to the U.S. reliance on employment-based health insurance.  The U.S. economy suffers from a job-lock rate of between 25 and 45 percent as a result of rising health care costs and health insurance underwriting practices.  Job lock occurs when a worker makes career decisions based on the imperative to maintain affordable medical insurance coverage or to avoid exclusion of a preexisting condition for herself or a family member.  As a growing number of U.S. workers seek, first and foremost, not jobs where their skills pay them higher wages but (increasingly scarce) jobs that provide them with good health insurance, then productivity, and eventually economic growth and the U.S. standard of living will fall.  In both France and the United States, the link between work and health insurance is a relic of the last century, ill fitted to fast-moving, information-based global economy.  Only if the link between health care financing and security from the calculations of workers and employers is severed will health care cease to hinder employment and economic growth.


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