A PRIMER ON FRENCH HEALTH CARE
A Comparative History of Health Care
Problems and Solutions in the United States and France
by Paul V. Dutton
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, SŽcuritŽ Sociale. A patient presents a
single microchip enhanced SŽcuritŽ 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 SŽcuritŽ 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 SŽcuritŽ 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 SŽcuritŽ 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 (SŽcuritŽ
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 SŽcuritŽ 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
SŽcuritŽ 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 SŽcuritŽ 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 SŽcuritŽ 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.