The United States spends an average $6,402 per person annually on medical care. France spends about half that — while providing better maternity benefits and complete coverage for people with conditions such as diabetes and cancer. Compare the systems.
In a book excerpt, Paul Dutton explains how the U.S. and French health care systems began to diverge during the 20th century and the unique factors that are pushing costs higher at a faster rate in the United States.
Reprinted from Paul V. Dutton, Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France. Copyright 2007 by Paul V. Dutton
In 2000, health care experts for the World Health Organization tried to do a statistical ranking of the world's health care systems. They studied 191 countries and ranked them on things like the number of years people lived in good health and whether everyone had access to good health care. France came in first. The United States ranked 37th.
Some researchers, however, said that study was flawed, arguing that there might be things other than a country's health care system that determined factors like longevity. So this year, two researchers at the London School of Hygiene and Tropical Medicine measured something called the "amenable mortality." Basically, it's a measure of deaths that could have been prevented with good health care. The researchers looked at health care in 19 industrialized nations. Again, France came in first. The United States was last.
Now some American experts say there's a lot Americans can learn from the French.
For starters, the French system is not what most Americans imagine, says historian Paul Dutton at Northern Arizona University, author of Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France.
"Americans assume that if it's in Europe, which France is, that it's socialized medicine," he says. "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."
France, like the United States, relies on both private insurance and government insurance. Also, just like in America, people generally get their insurance through their employer.
In France, everyone has health care. However, unlike in Britain and Canada, there are no waiting lists to get elective surgery or see a specialist, Dutton says.
He says the French want pretty much the same thing as Americans: choice and more choice.
Universal Coverage, Not At Expense Of Choice
Dutton says these shared values come out of a shared history. Both countries are products of Enlightenment-era revolutions.
"The French hold individual liberty and social equality very dear ... 'liberty, equality, and fraternity' — of course the slogan of their revolution," he says. "And in this country, of course, we have similar ideals: individual liberty, social equality — equal chances for everyone."
But the French have done a better job of protecting those values in health care, Dutton says.
Americans often assume that when people get universal coverage, they give up their choice in doctors, hospitals and care. That's not the case in France, Dutton says. The system is set up both to ensure that patients have lots of choice in picking doctors and specialists and to ensure that doctors are not constrained in making medical decisions.
In France, the national insurance program is funded mostly by payroll and income taxes. Those payments go to several quasi-public insurance funds that then negotiate with medical unions to set doctors' fees. (Doctors can choose to work outside this system, and a growing minority now charge what patients are willing to pay out of pocket.) The government regulates most hospital fees. This system works collectively to keep costs down.
When someone goes to see a doctor, the national insurance program pays 70 percent of the bill. Most of the other 30 percent gets picked up by supplemental private insurance, which almost everyone has. It's affordable, and much of it gets paid for by a person's employer.
"There are no uninsured in France," says Victor Rodwin, a professor of health policy at New York University, who is affiliated with the International Longevity Center. "That's completely unheard of. There is no case of anybody going broke over their health costs. In fact, the system is so designed that for the 3 or 4 or 5 percent of the patients who are the very sickest, those patients are exempt from their co-payments to begin with. There are no deductibles."
Treating The Sickest
In France, the sicker you are, the more coverage you get. For people with one of 30 long-term and expensive illnesses — such as diabetes, mental illness and cancer — the government picks up 100 percent of their health care costs, including surgeries, therapies and drugs.
France has made an unusual guarantee that every cancer patient can get any drug, including the most expensive and even experimental ones that are still being tested, says Dr. Fabian Calvo, deputy director of France's National Cancer Institute. This kind of access is why the French — unlike Americans — say they are highly satisfied with their health care system, he says.
"It's a feeling of safety — that if you have a big problem, you could have access to the good therapy," Calvo says.
When compared with people in other countries, the French live longer and healthier lives. Rodwin says that's because good care starts at birth. There are months of paid job leave for mothers who work. New mothers get a child allowance. There are neighborhood health clinics for new mothers and their babies, home visits from nurses and subsidized day care.
The Cost Of Care
It's expensive to provide this kind of health care and social support. France's health care system is one of the most expensive in the world.
But it is not as expensive as the U.S. system, which is the world's most costly. The United States spends about twice as much as France on health care. In 2005, U.S. spending came to $6,400 per person. In France, it was $3,300.
To fund universal health care in France, workers are required to pay about 21 percent of their income into the national health care system. Employers pick up a little more than half of that. (French employers say these high taxes constrain their ability to hire more people.)
Americans don't pay as much in taxes. Nonetheless, they end up paying more for health care when one adds in the costs of buying insurance and the higher out-of-pocket expenses for medicine, doctors and hospitals.
France, like all countries, faces rising costs for health care. In a country that's so generous, it's even harder to get those expenses under control.
Last year, the national health system ran nearly $9 billion in debt. Although it is a smaller deficit than in previous years, it forced the government of President Nicolas Sarkozy to start charging patients more for some drugs, ambulance costs and other services. Debates over cost-cutting have become an expected part of the national dialogue on health care.