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Tuesday, May 15, 2012

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.


Berliniquais said...

Hello Victoria,

Thanks for this riveting read. Indeed, I would not have thought that there are so many similarities between the two health systems, and Michael Moore's "Sicko" did not do much to help.

How little I have seen of the German health system makes me sorely miss our good old Sécu, but well, living abroad also means making a few sacrifices.

CarnetsdeSeattle said...

very good summary.

I get this question asked often a lot too and it pisses me off.

Last time at the support group, a friend asked me about this and then proceded to tell me in great detal about the hassle of the french administration and how it was a nightmare when her sister who lives in grenoble had to be tested for a bone marrow.

A few minutes later, another friend comments on how, (in the usa) she has been waiting for 2 weeks from the authorization from the insurrance to proceed with the transplant (which should be done has quickly has possible and from which the only alternative is death).

I was like: "Are you kidding? And you dare pretend that this system is better?"

It's not better, it's different.

There is also a very annoying tendency in the US to believe that they have the best treatment and that other countries still use flint and steel. Getting them to understand that I would have had the same exact protocol in France is hard.

Take care,

Victoria FERAUGE said...

@JM, yeah, I think Sicko (and anything by Moore) should be taken with a grain of salt. The Secu and I get along just fine these days though there was some "mefiance" on their part in the beginning. The French are very sensitive these days to foreigners coming in and using the healthcare system. Alas my accent gives me away almost immediately. So I started bringing in a big file with all my bulletins de paie (15 years worth) and it hasn't been a problem since. On the contrary they have been both efficient and kind.

@Loic, Irritating, isn't it? I've been hospitalized in both countries and frankly saw very little difference between the two. Great service, exactly the same treatments but a little less paperwork on the French side. Would have liked, however, to have had wi-fi during my hospital stay but, hey, I think it did me a world of good to disconnect for a week. :-)

Anonymous said...

Very enlightening. I'm not very familiar with the USA healthcare system, but I think you could add another similarity, la mutuelle (complementary health insurance) which many employers offer in the USA and France. In France it corresponds to the difference between the amount covered by the national social see curity and actual costs. I don't know exactly how it works in the USA.
What is likely not similar is (1) In France, individuals with no resources benefit from "universal" health care and this may also include a "mutuelle" (CMU). (2) In France, individuals not covered by company sponsored "mutuelle" (complementary insurance) can contract for one. The cost varies depending on the type of contract chosen but would be between 50 and 100 euros per month. The cost in the USA for health insurance, so I am told, could be more than $1000 per month (3) individuals in France can freely choose their healthcare provider, I believe in the USA, the company plans provide a list of agreed practitoners. I also understand that not all treatments are covered by the US healthcare insurers. (4) many doctors in France can be consulted at either a public hospital where there are longer waiting times for an appointment but little if any payment or at their private practice at a much higher cost but which is usually covered by the "mutuelle", if you have one.
(5) I am not familiar with public hospitals in the USA, but in France it is my experience that although they do not provide "hotel" type services, the medical care is excellent. Many French specialists/"professeurs" are residents in public hospitals. (6)In France, when you are absent from work due to illness, you continue to receive a portion of your salary, paid by the social security. Many employers make up the difference or it is covered by insurance. I don't know what the situation is in the USA

I find the healthcare in France to be outstanding. Unfortunately it comes with a high price tag and there will undoubtedly come a day of reckoning.

Victoria FERAUGE said...

@Anonymous: Thank you very much for the comment and for adding other similarities/differences. The article didn't really mention the "mutuelles" which is another point of convergence between the French and US systems. I can also confirm that US managed care systems do seriously limit access. Every insurance company I ever had in the U.S. had a list of approved doctors I could visit and required pre-approval for any procedure that was pricey. The medical care here is indeed excellent. One group of actors however is a big disgruntled and that is the doctors. I have 3 medical professionals in my family here (2 doctors, 1 nurse) and both doctors have considered a move to North America where they could command much higher salaries. The barrier was recertification - neither was willing to spend years studying for a license to practice in the destination country. Seems to be a bit easier in France and that may be another reason the costs here are lower: the state regulates the number of doctors trained, once trained those doctors can't necessarily leave easily to practice in other developed countries but the French state is open to bringing in foreign doctors. Needless to say, the doctors in my family found this to be an unreasonable state of affairs indeed.


Anonymous said...

I have to disagree with some of what you present in your article. First, let me point out that I'm an American and have lived in France for 27 years. So while I'm not up-to-date on US health care, I am very familiar with the French system.

You say:

"59% of the doctors are private and don't work for the state in any capacity."

While this is technically true, I recall what a physical therapist (kiné) I know once told me. He said that all health care professionals in France, unless they were working at "honoraires libres," or had chosen to set their own prices and not work with the Sécurité Sociale, were state employees indirectly. As long as you work in the system, you are a part of that system. There are very stringent requirements for how these people work if their services are going to be reimbursed.

I think it's worth noting that the health care system is much more than just doctors; there are physical therapists, nurses, dentists, and many others.

You say:

"doctors expect payment up front and people are only reimbursed for the expense after the care is provided."

This is true, but consider the cost of a visit to a GP (€23) or a specialist (generally €41). These costs are much lower than equivalent costs in the US. Yes, a minority can't afford even this, but they most likely have CMU. And the Sécurité Sociale reimburses people very quickly (though this used to not be the case).

As for ALD - affections de longue durée, or long-term illnesses - this is not for "life-threatening illness" as you say, but long-term illnesses that will require treatment and/or tests for a long period of time. It's a good thing that this is not automatic; can you imagine the potential for abuse? Also, it is only granted for 5 years, after which it must be renewed (but the renewal process is much quicker, and does not require the same type of review).

You are mistaken about "les partenaires sociaux;" these are not "economic actors in the private sector." These are unions, both for workers and for employers. They are a very restricted group of organizations, and the link you provide lists them.

I think it's worth comparing prices. For example, I have to get annual MRIs for a neurological condition. People in the US with the same condition pay $2000-3000 for this (naturally, if they have insurance, they don't pay all of it). In France, this is billed at around $200. Certain medications that I've had to take can be as much as 10 times as expensive in the US; if you consider co-pays, the amount people in France pay out of pocket is much less (assuming they don't have a mutuelle).

Finally, it's important to point out that the Sécurité Sociale covers much more than just health care. As a commenter points out, it also offers sick pay, "allocations familiales" (welfare payments to families), and retirement.

Anonymous said...

Also maybe France uses also a private-public system but it should be noted that all major illness (Affections de Longue Durée) are covered 100% by the state and represents two thirds of all health spending. Maybe for minor problems there isn't lots of differences between the two systems but I'd go back to France as soon as I have the slightest hint that I need major medical intervention.

Kirk said...

One other difference between the two systems: because of caps and limits to coverage for pre-existing conditions, people can go bankrupt in the US because of medical bills. This simply doesn't happen in France. One advantage of single-payer systems is the fact that all conditions are covered, and there is no such thing as "pre-existing conditiions."

Aaron said...

Of course without the caveat in your first paragraph, the two systems are worlds apart.

According to a Gallup survey (here: 17.7% of Americans lack health insurance and; therefore, only have access through emergency department visits. In France this would be absolutely unacceptable and despite all the systems' similarities this is too much of a difference to only casually mention.

Then, what about health care outcomes? "It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy." (NEJM:

The systems may look similar, but at the moment (especially as we wait for the SCOTUS decision on the ACA) they are so very different.

Victoria FERAUGE said...

@anonymous, Thank so you so much for the such a thoughtful comment. Your points are well-taken and I really appreciate your refining some of the author's arguments and evidence made in the article.

It reminded me that there is another similarity that is not mentioned in the article but I have seen up close: the constant stream of dug company representatives passing through the offices of healthcare professionals in both countries. Some really aggressive selling on their part and I've seen piles of free samples in the homes and offices of the medical professionals I know here that were given out in the hope that they would prescribe thus and such over the competition.

Concerning the doctors in the private sector I have a family member who was a doctor at a private clinic. It closed recently and he was officially laid off. This was a huge shock to the rest of the family who had assumed that he had more protection since he is a doctor and they thought he had a quasi-fonctionnaire status. Apparently not.

Victoria FERAUGE said...

Aaron, Kirk and anonymous: Good points all. How each system is actually lived by the people in is very subjective and really depends an enormous amount on personal circumstances. You might want to have a look at a blog that I follow regularly whose author is someone I've met and greatly admire. It's called Carnet de Seattle

Loic and his wife who are both French went to the U.S. back in 2009 for work. In March of last year he was diagnosed with leukemia. They did not return to France and he's being treated at a local Seattle hospital (same hospital where my daughter was born BTW). I'd invite you to read his posts to get a feel for how he has lived the American healthcare system.

What is interesting is that 1 year after his diagnosis, I got my own and I'm now living a part of the French healthcare system I kinda hoped that I would never have to learn about. ALD has now become a part of my vocabulary and I'm learning firsthand how it actually works in practice (as opposed to theory). So far I'm very very pleased with the care I'm receiving here but as Loic pointed out one day, I would get (and he got) the same care in the U.S. (protocols are the same).

So I'm going to stick with my sense that the two systems are surely different in many ways but also have some things in common. And just as Loic didn't hop on a plane for France when he was diagnosed, I'm not planning a trip back to the U.S. either. :-)


Kirk said...

Sorry to hear about your illness.

One thing you might not realize, since you live near Paris, is that being on ALD also means that you get transportation paid. For me in a rural département, that means taxis when I needed physical therapy that was unavailable from my local kiné, as well as when I went to see specialists in university hospitals. I don't think insurance in the US covers this, does it?

Aside from that, being on ALD doesn't make much of a difference. Your tests, doctors' visits and meds are covered without you having to lay out any cash, which can be helpful, but if you have a mutuelle, it generally comes out the same at the end of the month.

I hope you're getting better. I have a friend who has leukemia right now, and he seems to be doing well. As for protocols, for diseases like that, they are the same in most parts of the world. Western medicine is pretty consistent, as all doctors generally have access to the same info and drugs.

Victoria FERAUGE said...

Thanks, Kirk. Am trying to think of this as just another "aventure". Truth be told I'm meeting a lot of amazing people right now and I'm getting great care.

I had heard something about the transport but haven't looked into it yet. Will do very soon. Again, thanks for mentioning it.


Christophe said...

Here is my comment, as a French living in the US.
My experience with the healthcare system in both countries is similar: luckily, I have never had to experience anything traumatic: doctor visits, tests, and a couple outpatient procedures in both countries, and the birth of my children here in the US. Like Victoria, I am very lucky to work for a company that provides great health benefits. Even if it's gotten a lot worse in the past couple years, it's still way better than most.

I agree that the level of care is similar in both countries, both
excellent. Here are the points that struck me when I first moved here:

- Cost of course: my copay ($30) is more expensive than the price of the full consultation in France. But salaries are much higher, so copays are not really a big deal.

- Deductibles and coinsurance.
I only knew these notions from car insurance in France, and that shocked me that this would apply to health insurance as well. This is where it can get expensive.
Your insurance kicks in only after you met your deductible, which can be high (per person/per family)

- When you go to the doctor, you spend more time with a nurse who takes your vitals and asks you about your condition than with the doctor himself. It seems inefficient to me, as the doctor could have done it himself, and a way that information could be deformed when passed from the nurse to the doctor. Some think that this way doctors can see many more patients, but I am not sure the additional number of patients really makes up for the salary of the nurse.

- Pharmaceutical companies spending huge amount of money to advertise PRESCRIPTION ONLY drugs on TV, while still advertizing to doctors who will give you free samples of for example allergy prescription medication. I wish they would not waste all that money and accordingly reduce the price of their drugs. Some non generics antiobiotics can have a copay as high as $100!

- Itemized hospital bills for the birth of my kids was outrageous.

- Learning that my company was "self insured".

- In-Network and Out of Network notion, and the difference in price between the two.

- Learning about preexisting conditions and he impossibility for people to get insurance and care is something that is difficult to understand for people who are used to universal health care.

- Bankrupties associated with medical costs.

- People raising money to pay for their medical bills.

- Life time maximums in healthcare policies.

Would I go back to France to get care? Not if I can still get the coverage I have with my employer. But if I were to lose my job and health insurance, I will seriously consider finding a job back in France. I am too proud to beg for money to and have fundraisers to help pay for medical bills.

Improving health care in America is a challenging issue. It is just sick that the policies are driven by who provides more money to have the politicians vote in their favor, than for the good of the American people. This nation is the one that first sent someone to the moon. I don't understand why it cannot tackle this issue/challenge from a more pragmatic way.

Victoria FERAUGE said...

@Christophe, Thanks you so much for leaving a comment about your perspective. I really liked your point about how the doctors' offices are staffed in the U.S. I had the same experience and I also noticed that there was always at least one staff member (not a medical professional) dedicated to managing all the different insurance programs that patients were using.

Pragmatism is in short supply these days in both countries. I think the public in both is primarily driven by fear - fear that whatever the shortcomings of the existing systems, change will only be for the worse.

But change comes whether we like it or not because the world changes and adaptation is necessary. A friend sent me this link about a new unanticipated wrinkle in the government-managed part of the US healthcare system: veterans. They say nearly 50% of the armed services personnel coming back from Irak and Afghanistan are requesting medical care and disability for conditions related to their service.


Anonymous said...

I live in France part of the year and have been sick twice, once in 2005 with bronchitis, and in 2006 with pneumonia. I arrived off the plane in Toulouse with the bronchitis. Came down with the pneumonia while on holiday in Nice.

For the bronchitis I visited my local doctor in a village near my home. He examined me thoroughly, including chest xray, sputum and throat cultures - no nurse. He diagnosed me, gave me a prescription for 4 drugs, then pulled out a laminated sheet of paper that had fees on it, and pointed to 'non-resident alien- €23', AND apologized for having to charge me so much. All 4 drugs, including 2 antibiotics, came to €14. I dare say that would have cost me $300 in the US and I would have paid it all as I have high-deductible insurance for the self employed.

In Nice I asked the front desk at my hotel how to see a doctor - "No problem, Monsieur. I will have one here within the hour." When the doctor arrived, at my room, he gave me a thorough physical, listened to my chest carefully and pronounced pneumonia, gave the front desk my prescriptions and left. My prescription arrived in less than an hour. When I checked out two days later the doctor's bill was on my facture - €100, the 3 drugs €30. I'm not sure I could even get a house call in the US, much less at such a trivial rate.

I have a retired friend near Bordeaux who moved back to France entirely because of US health care. He sold his house in Santa Fe, bought a condo near his family and moved last year. I had dinner with him and his wife a few weeks ago, and he told me that he and his wife had always assumed they would return to France after retirement - because of superior health care. They are about 80, so they waited. Still... Just saying.

Victoria FERAUGE said...

Hi Anonymous, Thank you so much for your comment and for relating your experience. Yes, French doctors do house calls which I find absolutely wonderful. It was a godsend when the Frenchlings were little. When we lived in the US our only option for an ear infection in the middle of the night was the local children's hospital. Here it was simply a matter of calling whatever local doctor was on call that night and having him/her come to the house. Just amazing. And as you so rightly mention, the price is definitely affordable.


Anonymous said...

Wow! Such an interesting entry. The issue of a nation’s health care system is so complex in that pros and cons would naturally be present. And since not every individual has the same health issues, some would receive a certain health care system more favorable than the others. I’m glad you were able to present both cases of the American and French health care well. Thanks for sharing!

Steve Fischer

Victoria FERAUGE said...

Hi Steve,

Hey thank you for stopping by the Flophouse and for the comment. Yes everyone's mileage will vary here. What's interesting is that underneath it all are common goals but different ways of getting there.

All the best,


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