French and American Healthcare - Not So Different After All

If I had a centime for every time someone asked me which is better, American or French healthcare, I'd be able to buy all the Gucci purses I've been coveting for years.  The honest answer is, and this is just my personal experience, they are both pretty good (Japan too) but each has its advantages and disadvantages.   Of course I'm speaking as someone who had very good private insurance in the U.S. and never was one of the millions of Americans who do without.  On the French side, I'm a legal resident here so I've always been covered by the national healthcare system.  So when I talk about this, recognize that my experience is limited.

Recently I came across an article published in 2011 by the Institut de Recherche en Sante Publique which offers a very interesting comparison of the two systems and asks a far more daring question - how are the two systems alike?  Alike, you say?  What does a national healthcare system (pure Socialism according to Americans) have to do with a inegalitarian private system (Capitalism at its worst say the French) have in common?  More than you might think and some of the differences are not obvious ones.

Regards croisés sur les systèmes de santé américain et français by Didier Tabuteau (Directeur de la Chaire Santé de Sciences Po, Paris, France) and Victor Rodwin (Professor of Health Policy and Management, Robert F. Wagner Graduate, School of Public Service, New York University, New York, USA) argue convincingly that the systems are, in fact, quite similar with the French system resembling the U.S.  far more then it does other European national healthcare systems like Sweden's or the UK's.  Let's consider their evidence for such a claim:

Choice:  In France, you might be surprised to learn, the private sector has a large role to play in the public health system.  59% of the doctors are private and don't work for the state in any capacity.  They are independent, can charge what they like and can offer their services to anyone they please.  This means that the French public has a great deal of choice when it comes to picking a doctor - the only limitations are the doctor's schedule and the price.  A French person can choose a doctor whose fees match what is reimbursed by the system, or he/she can go to a more expensive healthcare professional and pay the difference out of his own pocket.  There is also an extensive network of private clinics and hospitals here in the Hexagone.  No French person is obliged to turn to the public sector facilities if he or she has the means to choose something else.  Consider the implications of this:  someone with money in France can buy better care and have more choice.  Nothing wrong with that in my view but it's not exactly "égalité".

Government intervention:  Americans seem to be perfectly happy to have government intervention in in the American healthcare system in some areas.  Like France there is a booming private sector but also like France the government runs public hospitals, puts public money into medical research and maintains public systems parallel to the private one.  Tabuteau and Rodwin point out that all of the following are public organizations funded by the state using taxpayer money:  Veterans Health Administration (VHA),  National Institute of Health (NIH), Food and Drug Administration (FDA), and the Center for Disease Control (CDC).  And then there is Medicare - a full-blown social insurance program that guarantees healthcare for Americans over the age of 65 and some younger Americans with catastrophic health conditions.  While there has been a lot of debate about the system (its efficiency, cost and so on)  older Americans seem to like it and react badly when politicians imply that it should be privatized.  Since retirees vote in large numbers and have ample time to write letters and attend "manifestations" it is unlikely that this system will disappear anytime soon.

Access to preventive healthcare:  In this area both systems have problems.  The French system does have co-pays, not everything is 100% covered, not to mention that doctors expect payment up front and   people are only reimbursed for the expense after the care is provided.  Not a huge deal for most people but it does prevent a small minority from benefitting fully from regular check-ups.  Even 100% coverage for life-threatening illness is not automatic - a person must file paperwork with the local Social Security office and have his case examined by a government doctor before it is validated.  In the U.S. a lack of insurance for a certain percentage of the population has the same effect.  People go to the doctor when they must and skip checkups which might prevent a disease caught in the early stages from becoming a very costly (and potentially mortal) condition.

Cost:  Both countries spend an enormous amount of money on healthcare.  "Ils occupent les deux premieres places du classement mondial de la part de la richesse nationale - le PIB- consacrée a la santé."  The U.S. wins the prize however by spending twice as much per person as France while not providing anything close to universal coverage.  Why?  Compared to France everything in the U.S. related to healthcare costs more whether its a basic trip to the doctor or an MRI scan.  The other factor is the sheer cost of administration.  In France, the country of the much-loved "functionnaire" (government worker), administrative costs for healthcare are surprisingly reasonable - only about 4%.  In the U.S. it is nearly double that:  7.5% on average and up to 20% if one adds in the cost of risk management for hospitals and private insurance managed care schemes.

Public health organization:  One result of the fairly limited national healthcare administrative costs in France has a rather perverse result according to Tabuteau and Rodwin.  The social insurance system may be a large government-run system guaranteed as a basic right but the actual costs of administration and overall organization of the French public healthcare system are delegated to what are called "les partenaires sociaux" ("les agents économiques qui participent à des négociations d'ordre social") - in other words economic actors in the private sector.   The situation is the exact opposite in the U.S. where it is the government that heavily regulates and routinely intervenes quite firmly in the area of public health.   It's not just the power and prestige of institutions like the CDC, it is also the imposition of management systems like the government-mandated  uniform reporting system for healthcare facilities.

Reform:  Since the year 2000 France has moved more toward a system that is a convergence between public and private with private insurance companies and healthcare facilities having an even more important role to play than they did in the past.  In 2014 the U.S. (provided that the courts agree) will move ever so slightly in the direction of European-style healthcare systems with a mandate that companies provide healthcare for their employees and that individuals be required to purchase some sort of healthcare insurance.  The issue is the same in both countries regardless of how healthcare is organized and delivered since the costs are becoming a major political and economic problem.  The question really is:  how do you save what's good about both systems without bankrupting either country?

That is a conundrum that politicians and voters on both sides of the Atlantic will be grappling with for the foreseeable future.  One thing is sure, however, limiting access to healthcare to legal residents and citizens (and denying it to other migrants or illegal immigrants) isn't going to balance the books and preserve the system in either country.  Immigrants are not responsible for the outrageous administrative costs in the U.S. (that's due to the fractured nature of the system).  In France, even if it was decided tomorrow to deny access to every undocumented person and restrict the access of short-term migrants, this wouldn't even put a minor dent in the deficit.   No easy answers, folks, no simple solutions and citizens in both countries need to wake up, smell the coffee and set aside the kool-aid proposed by their very dishonest and self-serving politicians.