A model health care system

A model health care system

By Paul V. Dutton

The Boston Globe

Monday, August 13, 2007

Many advocates of a universal health care system in the United States look to Canada for their model. While the Canadian system has much to recommend it, there's another model that has been too long neglected. That is the health care system in France.

Although the French system faces many challenges, the World Health Organization rated it the best in the world in 2001 because of its universal coverage, responsive health care providers, patient and provider freedoms, and the health and longevity of the country's population. The United States ranked 37.

The French system is also not inexpensive. At $3,500 per capita it is one of the most costly in Europe, yet that is still far less than the $6,100 per person in the United States.

An understanding of how France came to its health care system would be instructive in any renewed debate in the United States.

That's because the French share Americans' distaste for restrictions on patient choice and they insist on autonomous private practitioners rather than a British-style national health service, which the French dismiss as "socialized medicine." Virtually all physicians in France participate in the nation's public health insurance, Sécurité Sociale.

Their freedoms of diagnosis and therapy are protected in ways that would make their managed-care-controlled U.S. counterparts envious. However, the average American physician earns more than five times the average U.S. wage while the average French physician makes only about two times the average earnings of his or her compatriots. But the lower income of French physicians is allayed by two factors. Practice liability is greatly diminished by a tort-averse legal system, and medical schools, although extremely competitive to enter, are tuition-free. Thus, French physicians enter their careers with little if any debt and pay much lower malpractice insurance premiums.

Nor do France's doctors face the high nonmedical personnel payroll expenses that burden American physicians. Sécurité Sociale has created a standardized and speedy system for physician billing and patient reimbursement using electronic funds.

It's not uncommon to visit a French medical office and see no nonmedical personnel. What a concept: no back office army of billing specialists who do daily battle with insurers' arcane and constantly changing rules of payment.

Moreover, in contrast to Canada and Britain, there are no waiting lists for elective procedures and patients need not seek pre-authorizations. In other words, like in the United States, "rationing" is not a word that leaves the lips of hopeful politicians. How might the French case inform the U.S. debate over health care reform?

National health insurance in France stands upon two grand historical bargains - the first with doctors and a second with insurers.

Doctors only agreed to participate in compulsory health insurance if the law protected a patient's choice of practitioner and guaranteed physicians' control over medical decision-making. Given their current frustrations, America's doctors might finally be convinced to throw their support behind universal health insurance if it protected their professional judgment and created a sane system of billing and reimbursement.

French legislators also overcame insurance industry resistance by permitting the nation's already existing insurers to administer its new health care funds. Private health insurers are also central to the system as supplemental insurers who cover patient expenses that are not paid for by Sécurité Sociale. Indeed, nearly 90 percent of the French population possesses such coverage, making France home to a booming private health insurance market.

The French system strongly discourages the kind of experience rating that occurs in the United States, making it more difficult for insurers to deny coverage for pre-existing conditions or to those who are not in good health. In fact, in France, the sicker you are, the more coverage, care and treatment you get. Would American insurance companies cut a comparable deal?

Like all health care systems, the French confront ongoing problems. Today, French reformers' first priority is to move health insurance financing away from payroll and wage levies because they hamper employers' willingness to hire. Instead, France is turning toward broad taxes on earned and unearned income alike to pay for health care.

American advocates of mandates on employers to provide health insurance should take note. The link between employment and health security is a historical artifact whose disadvantages now far outweigh its advantages. Economists estimate that between 25 and 45 percent of the U.S. labor force is now job-locked. That is, employees make career decisions based on their need to maintain affordable health coverage or avoid exclusion based on a pre-existing condition.

Perhaps it's time for us to take a closer look at French ideas about health care reform. They could become an import far less "foreign" and "unfriendly" than many here might initially imagine.

--------------

Paul V. Dutton is associate professor of history at Northern Arizona University and author of "Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France." This article first appeared in The Boston Globe.