Taking Care of Youngsters and Mothers
posted at 7/17/2008 4:55 AM EDT
Instructive to see how France has achieved a globally acclaimed health care system and barely half the cost of our dysfunctional one.
France's model healthcare system
MANY advocates of a universal healthcare system inthe United States look to Canada for their model. While the Canadianhealthcare system has much to recommend it, there's another model thathas been too long neglected. That is the healthcare system in France.
Althoughthe French system faces many challenges, the World Health Organizationrated it the best in the world in 2001 because of its universalcoverage, responsive healthcare providers, patient and providerfreedoms, and the health and longevity of the country's population. TheUnited States ranked 37.
The French system is also notinexpensive. At $3,500 per capita it is one of the most costly inEurope, yet that is still far less than the $6,100 per person in theUnited States.
An understanding of how France came to its healthcare system would be instructive in any renewed debate in the United States.
That'sbecause the French share Americans' distaste for restrictions onpatient choice and they insist on autonomous private practitionersrather than a British-style national health service, which the Frenchdismiss as "socialized medicine." Virtually all physicians in Franceparticipate in the nation's public health insurance, Sécurité Sociale.
Theirfreedoms of diagnosis and therapy are protected in ways that would maketheir managed-care-controlled US counterparts envious. However, theaverage American physician earns more than five times the average USwage while the average French physician makes only about two times theaverage earnings of his or her compatriots. But the lower income ofFrench physicians is allayed by two factors. Practice liability isgreatly diminished by a tort-averse legal system, and medical schools,although extremely competitive to enter, are tuition-free. Thus, Frenchphysicians enter their careers with little if any debt and pay muchlower malpractice insurance premiums.
Nor do France's doctorsface the high nonmedical personnel payroll expenses that burdenAmerican physicians. Sécurité Sociale has created a standardized andspeedy system for physician billing and patient reimbursement usingelectronic funds.
It's not uncommon to visit a French medicaloffice and see no nonmedical personnel. What a concept. No back officearmy of billing specialists who do daily battle with insurers' arcaneand constantly changing rules of payment.
Moreover, in contrastto Canada and Britain, there are no waiting lists for electiveprocedures and patients need not seek pre-authorizations. In otherwords, like in the United States, "rationing" is not a word that leavesthe lips of hopeful politicians. How might the French case inform theUS debate over healthcare reform?
National health insurance inFrance stands upon two grand historical bargains -- the first withdoctors and a second with insurers.
Doctors only agreed toparticipate in compulsory health insurance if the law protected apatient's choice of practitioner and guaranteed physicians' controlover medical decision-making. Given their current frustrations,America's doctors might finally be convinced to throw their supportbehind universal health insurance if it protected their professionaljudgment and created a sane system of billing and reimbursement.
Frenchlegislators also overcame insurance industry resistance by permittingthe nation's already existing insurers to administer its new healthcarefunds. Private health insurers are also central to the system assupplemental insurers who cover patient expenses that are not paid forby Sécurité Sociale. Indeed, nearly 90 percent of the French populationpossesses such coverage, making France home to a booming private healthinsurance market.
The French system strongly discourages the kindof experience rating that occurs in the United States, making it moredifficult for insurers to deny coverage for preexisting conditions orto those who are not in good health. In fact, in France, the sicker youare, the more coverage, care, and treatment you get. Would Americaninsurance companies cut a comparable deal?
Like all healthcaresystems, the French confront ongoing problems. Today French reformers'number one priority is to move health insurance financing away frompayroll and wage levies because they hamper employers' willingness tohire. Instead, France is turning toward broad taxes on earned andunearned income alike to pay for healthcare.
American advocatesof mandates on employers to provide health insurance should take note.The link between employment and health security is a historicalartifact whose disadvantages now far outweigh its advantages.Economists estimate that between 25 and 45 percent of the US laborforce is now job-locked. That is, employees make career decisions basedon their need to maintain affordable health coverage or avoid exclusionbased on a preexisting condition.
Perhaps it's time for us totake a closer look at French ideas about healthcare reform. They couldbecome an import far less "foreign" and "unfriendly" than many heremight initially imagine.
Paul V. Dutton isassociate professor of history at Northern Arizona University andauthor of "Differential Diagnoses: A Comparative History of Health CareProblems and Solutions in the United States and France," which will bepublished in September.