Is French Health System A Model For U.S.?

PARIS _ Houston native Jennifer Hua gave birth to her first two children in Texas, and her last two in France. The Houston hospital looked like a luxury hotel. The hospital in Paris was a converted prison.

Amenities aside, she prefers Paris.

The American health care model, she says, is too expensive and too insecure. France offers her family good medical treatment, better insurance, more convenience and no worries about how to pay medical bills if her husband's job changes.

"If we were to consider returning to the U.S., health care would be one of my top concerns," the Rice University alum said.

Dallas native Anna Marie Mattson heads the University of Texas alumni group in France (Texas Exes). She's lived in Paris since 1990 and has seen members of her family go through hospitalizations. Mattson says the French model encourages people to put health ahead of economic anxiety.

"Under the U.S. system, I never wanted to get sick, and when I did, I went to the pharmacy to try to find a way to treat myself," she said. "In France, you go to the doctor immediately."

As America seeks a better way to provide medical care, France offers an example of a system where everyone has government-provided, basic health insurance _ citizens and immigrants alike. Expenses for such chronic illnesses as cancer, diabetes and multiple sclerosis are covered entirely by the state so patients can focus on treatment rather than financial ruin.

But if France is instructive on health security, it also shows how high, vexing medical bills push government into a constant reform struggle. Lately, the French are taking a page or two from the U.S. playbook to try to cope by exploring managed-care practices.

Rice University alum Elizabeth Dutertre, who's lived in France since 1968, has had good and bad experiences with French health care.

"Many liberal Americans are convinced that the French system is the be-all and end-all solution to health care costs in the United States," she said. "But the system is costly to both the workers and the state. In fact, it is going bankrupt."

Bankruptcy looms for America as well. Health care absorbs more than 17 percent of the U.S. economy, or $2.4 trillion. The French fork over 11 percent.

In 2006, U.S. spending averaged $6,714 per person. The average resident of France spent $3,450. This year, U.S. spending is expected to near $8,000 per person, while French officials estimate spending there will come in below $5,000. It's not that the French are younger. One in six of France's 61 million people are over the age of 65; one in eight Americans are over 65.

France and the United States pay for their health care in different ways. Most U.S. health care spending is private. The government's share _ what you pay for in taxes for Medicare, Medicaid, military and other government employees _ is 46 percent. The rest is paid through insurance split between employers and workers, and in out-of-pocket expenses borne by consumers.

In France, national health insurance pushes the government's share of health care spending to 80 percent. Consumers and their employers pay for the rest through supplemental, private insurance and out-of-pocket expenses.

In both countries, patients with the money to pay for more or better care not covered by insurance are able to buy it through private clinics and doctors. Health expenditures have grown faster than prices for nearly everything else in both countries for many years, despite decades of reforms aimed at capping prices, supply and demand.

President Barack Obama has made a priority of providing health insurance for all Americans while lowering health care inflation. France has insurance for all but battles health care costs in the National Assembly every year.

People in both countries tell pollsters that rationing health care is abhorrent, but both ration by price. American and French men and women who make too much money to qualify for indigent care, but too little to afford comprehensive insurance, often go without needed medical treatment.

France blends public and private insurers and hospitals with (mostly) self-employed doctors. There's a national insurance plan that covers between 60 and 70 percent of health care spending for everyone. (Forty-six million Americans do not have health insurance.)

In France, private companies and trade groups offer supplemental health insurance. Consumers use it to pay the charges not covered by national insurance.

Although U.S.-style managed care has started creeping in, the French insurance system leaves consumers free to choose their doctors and leaves French doctors free to make whatever prescriptions and treatment recommendations they think best.

Everyone who's lived in France for at least three months is covered by national health insurance.

People with chronic illnesses get continuing medical attention without facing a bill for it. Treatments and survival rates for cancers and other diseases are better in the United States, although French cancer patients routinely get access to experimental drugs.

Far more Americans get heart surgeries to clear clogged arteries, but the French death rate from heart attacks is about one third of the American rate.

The French live longer. They have more hospital beds and more doctors.

For health economist Didier Tabuteau, though, there is one overriding difference between the U.S. and French systems.

"The difference is the price, not the number of doctors or the number of hospitals," he said. "You pay a very high price for drugs and doctors."

The French government negotiates price ceilings with pharmaceutical companies. French doctors earn about 60 percent of what their American counterparts make, although they get free medical school tuition and don't face high malpractice insurance premiums.

Like us, however, the French have a looming problem with the cost of medical care. If the American way is generous to doctors and drug makers, the French way is generous to consumers. With no deductibles and with out-of-pocket expenses averaging less than $250 a year, the French visit their doctors about twice as often as Americans. The French lead the world in drug consumption.

Cost-control steps taken over the last 20 years have created a two-tier system where medical care is readily available to the very poor and those who are well off. It's harder to come by for the lower middle class who can't get comprehensive, supplemental health insurance through their employers and can't afford to buy such policies on their own.

Tabuteau says a third of French consumers complain they can't get the dental care, eyeglasses or other treatments they want because of cost.

Jennifer Hua and her French husband can choose any doctor they want. They've had their pediatrician come to the house on a Sunday to care for a sick child.

The Huas pay their doctors at the time of service for house calls and office visits, but their insurance deposits reimbursements into their checking account in a matter of days. All of their medical care is covered by two health insurance policies that together cost them 77 euros a month, or about $102. The Huas used to spend another $100 a month for a better supplemental insurance policy than the one offered by Mr. Hua's employer, but they dropped that policy after he switched to a job with better benefits.

Insurers and providers use a common electronic billing system tied to identity cards that carry a microchip containing reimbursement information. Health economist Gerard de Pouvourville said the system's efficiency reduces overhead to less than 4 percent of the plan's cost.

For several years, a team of researchers at Harvard Medical School has argued that up to a third of the U.S. medical bill goes toward overhead for insurance companies, marketing, hospital and physician billing departments, pharmaceutical advertising and the like.

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(Insurance firms and others dispute that overhead estimate. Comparable estimates for France are hard to come by. The Paris-based Organization for Economic Cooperation and Development collects health care overhead estimates from governments showing France at 6.9 percent, and the U.S. at 7.5 percent. OECD health data expert Gaetan Lafortune says both estimates are too low.)

In France, the national insurance plan's trustees negotiate a fee schedule with physicians' unions and hospitals. An office visit with a general practitioner costs 23 euros, or about $30. Patients are expected to pay one euro of that cost out of their own pockets. Insurance reimburses them for the rest.

Most doctors stay within the plan, but about 30 percent have opted out and are free to charge what they like. (Leaving the plan cuts them out of a government-funded pension.)

Employers contribute 12.8 percent of employee compensation for national health insurance. Workers contribute 0.75 percent. Chronic deficits have forced the government to add large amounts of tax revenues to health insurance financing, including a 5.25 percent income tax surcharge.

Tabuteau, head of the Department of Health Policy and Management at the Institute of Political Studies in Paris, warns that this is an inadequate model that will force the French government to either raise employee contributions or limit national health insurance to the 10 million people with chronic illnesses.

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Elizabeth Dutertre has had three surgeries to correct double vision. The first was at the Hotel-Dieu, a public hospital across the street from Notre Dame Cathedral, where an unexpected opening in her surgeon's schedule let her get an operation within two months of diagnosis.

"At the end of it, I had nothing to pay," she said.

The second time, she was told it would take two years before her surgeon could schedule her at a public hospital. She went instead to a private hospital, where her surgeon operated within three weeks. At discharge, she got a bill for 350 euros, or about $465.

"They immediately wanted a check _ no Visa card, no American Express," she said. "If you can afford the out-of-pocket expense, you get quicker, better care."

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Dr. Marie-Laure Alby, a general practitioner in Paris who shares a practice with three other doctors, said government-set fees don't provide enough money to cover expenses. The practice where she works offers patients care six days a week, 12 hours a day, including house calls. The four doctors share the cost of two secretaries and one nurse.

General practitioners in France earned about $84,000 in 2004, or $62,000 less than their American counterparts, according to the latest estimates collected by the OECD.

"The solution would be to have more money if you offer a better service," she said.

Alby no longer works within the government fee schedule. Instead of charging $30 for an office visit, she charges $42.

"It's about one-tenth of what you pay in the States," she said.

Alby argues consumers are too used to the idea that health care should be free.

"In France, one specific problem is the emergency room of the hospital," she said. "Many people in France would think less about going there than they would to go to a cafe."

Patients who go to a public hospital emergency room aren't given a bill to pay at the end of their treatment.

None of this is free, of course. The share of taxes in the French economy is more than 40 percent. In the United States, it's just over 25 percent.

The French government knows about emergency room overuse but has not cracked down.

"It's a pure scandal," Alby said.

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