Americanexpatinfrance's Blog

An original piece originally published in September on Scoop44 (now ScoopDaily):

By Michael Barrett / September 7th, 2009

As the healthcare debate remains intense in Washington and across the country, leaving fiery protests at town hall meetings in its wake, one way to have a more knowledgeable discussion is by looking to examples of healthcare in other countries.

The Obama administration has been criticized by some conservatives as wanting to impose a socialist system in not just healthcare but also in economic matters. One of the countries referred to the most by both critics and proponents of Obama’s policies is France, the supposed beacon of socialism and the welfare state. It is important, however, to get beyond ideologies and examine the facts. What could the U.S. learn from the French healthcare system, both what to do and what not to do?

France’s public health system provides a basic form of mandatory health coverage for everyone, including foreign residents like myself with valid working papers. The main fund, Sécurité Sociale (Sécu), covers 80 percent of the population, and two other entities exist for the self-employed and agricultural workers. France also provides options for those ineligible for Sécu or below a certain salary threshold.

Everyone covered by the system uses a health insurance card resembling a debit card, called a Carte Vitale. This is equipped with a computer chip that can be read by doctors’ and pharmacists’ computers to access a patient’s insurance coverage information. All French citizens from 16 years old are required to have one; those younger are on their parents’ plans. While practical, this card can represent the excessive paperwork and hurdles that foreign residents must get through in order to obtain one. It took me several months to get my Carte Vitale, somewhat delayed because I had provided one too many pieces of identity for their comfort.

This notorious bureaucracy makes even the French cringe, but there is a silver lining: when getting laid off from a job does not result in losing a steady health insurance plan, the benefits seem worth the hassle. These are reaped not only individually but also economically. Indeed, the French social safety net played a role in bringing France officially out of the recession this past quarter, providing a stable foundation for increased consumption and other economic activity.

In addition to the public system, there exists a huge private market for health insurance in the form of supplementary medical plans known as mutuelles. These tend to pay for some of the costs not covered well by Sécu. Most French opt for these; the Boston Globe puts the rate at 90 percent of the population. For non-E.U. citizens moving to France, private medical insurance is mandatory.

These mutuelles are run by private insurers that offer a variety of plans to different groups, from students to professionals (and this is again subdivided into job sectors, like teachers). They often cover expenses not already paid for by the Sécu. For example, the standard doctor’s consultation will cost 22€ (about $31) and Sécu will normally reimburse 70% of this, or 15.40€. The mutuelle will usually make up some or all of the difference. My mutuelle is with the LMDE (la mutuelle des étudiants – student’s private option), which along with the other student option (SMERRA),offer beneficial plans to students in coverage and cost.

I just upgraded mine, and it will help cover most prescription costs, doctor visits, some dental and eye appointments as well as hospital stays. The cost for my total coverage per year? 393€ (195€ for Sécu, 198€ for LMDE) – about $560 a year ($47 a month). Not bad, considering that this covers the entirety of my asthma prescription costs for medicines I take daily, for which I’d pay a lot in the U.S. even with insurance. Not to mention a good portion of the costs incurred for hospital visits, dentist appointments and other procedures.

This is one of the key differences between the French and American systems. In the U.S., if you are prone to illness or have a chronic condition, health insurance providers will often either increase your payments or drop your coverage. As stated in the Boston Globe article, the French system makes it “more difficult for insurers to deny coverage for preexisting conditions or to those who are not in good health.”

Another difference is that associated with unemployment. If you lose your job in the U.S. and are not covered by government employee plans, you will likely have to pay more for private health insurance than through a company-provided scheme. In France, everyone is covered by the public option so that even those laid off by their employers don’t have to fear enormous costs in going to the doctor in case of illness.

One more aspect is that when ambulances are dispatched to treat injuries, a doctor comes along with appropriate equipment to start treating the patient at the scene before going to the hospital for further care. This was featured by CBS news.

The benefits can be seen in many ways, such as life expectancy: France is ranked 7th among UN nations (77 years for men, 84 for women), whereas the U.S. is at 35th (75 for men, 80 for women). Moreover, the World Heath Organization (WHO) has ranked France’s healthcare system as the best (though debatable). Indeed, according to the Boston Globe article, France’s ranking is based on “its universal coverage, responsive healthcare providers, patient and provider freedoms, and the health and the longevity of the country’s population.” The U.S. comes in at a meager 37th place. People like Fox News anchor Glen Beck should reconsider their statements.

Image: The Economist

So we see that the system in France has positive aspects, but what could be the costs of such a universal scheme? It does not come cheap, at about $3500 per capita (Boston Globe), but it is much less expensive than the U.S. ($6100). In terms of overall spending, France devotes 10.5% of its GDP to healthcare, whereas America spends 16%. More on the U.S compared to other countries of the Organization for Economic Cooperation and Development (OECD) can be found in this 2004 report. As addressed by Medical News Today, the financing for the public health system is provided for by employers, employee contributions and personal income taxes, with around 20 percent of a working person’s gross salary deducted to pay for the Sécu.

There should be no surprise, therefore, that French authorities are trying to cut down on costs in the system. According to this article, instead of years ago when people would go to any doctor they wanted, “family doctors must now coordinate treatment.” I have witnessed this in France, where a patient must have the approval of his or her general practitioner before going to a specialist for a specific problem (exceptions: gynecologists, ophthalmologists and dentists – no need for referral).

There certainly needs to be reform in the U.S. of some sort. Indeed, the majority of Americans view the U.S. health system as “average” or “below average” according to the Pew Research Center. Even if a public option comes into existence in the U.S., it would likely not be mandatory for everyone, unlike the French system. The crux of the debate is whether or not a government-run public option would result in healthy competition with private insurers and lower premiums or if it would dominate the market and be a weight on business. A public health insurance option in the U.S. might dramatically increase coverage, but it will be vital in the long-term to reduce cost. Streamlining government bureaucracy could contribute to that endeavor.

Policymakers in Washington would be wise to take heed from French lessons of mixing public with private insurers. According to the American Journal of Public Health, these lessons include: “the importance of government’s role in providing a statutory framework for universal health insurance” and “understanding that universal coverage can be achieved without excluding private insurers from the supplementary insurance market.”

We can learn from France without becoming France, taking what works and leaving aside any nuisance to long-term growth while encouraging innovation to reduce costs, increase coverage and improve medicines. Our collective health depends on it.

If you would like a very in-depth analysis of the benefits and pitfalls of France’s whole economic system, I invite you to read the Economist article cited here. You can find more info on the French social protection system here and on this site.