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April 27, 2006

The French Health Care System

Over at QandO, Dale Franks has a long post up about the French and German health systems that deserves a read but requires some serious corrections and context. As he sort of notes, the French system is a mostly public structure, with the majority of citizens buying private insurance on top of it -- the government provides the floor, your bank account decides the ceiling. The government subsidizes extra insurance for the poor.

Franks also notes that the system has staggering deficits. Well, I guess so. But not as staggering as, you know, our deficits. And it's also not crushing any of their major industries in the way our system has helped destroy our automakers. And France spends about 10% of their GDP to give everyone unlimited care, we spend 15% and have 46 million uninsured, and 15 million more underinsured. Put another way, we spend $5,600 per capita even with the downward drag of the 46 million uninsured. France spends $2,900 and everyone is covered.

So I think Franks should be a bit more honest about the context for his comparisons. Elsewhere, he writes (italics mine), "Prior to the implementation of the CMU in 2000, the French Government estimated that up to 25% of the population delayed getting medical care for financial reasons. Let's call that an "unofficial waiting list." Do I really need to make the obvious rebuttal? Because if so, America has an "unofficial death list." And, in any case, the portion I italicized notes that the following sentence simply doesn't hold true any longer.

Franks also goes on a weird rant about private insurers not covering things for predefined periods, a problem that affects only the smallest slice of the population because the government pays for basically everything, subsidiary insurance is to reduce copays and deductibles. The post basically goes on like that, weird, quasi-truthful nitpicks that identify the same problems we have domestically, only in France they aren't a tenth so bad and cost half as much. Still, Franks prefers our system. Sometimes I wonder if the free market isn't faith-based.

The first comment over at QandO is actually pretty funny though. Put a bit shorter, it's the usual conservative hue and cry: "Your study is fatuous! The facts are biased! I have anecdotes! Anecdotes!!!!!!"

If you're interested in more, here's the story of a conservative pundit's conversion to socialized medicine. He was living in France and got cancer. Cathy Seipp had an op-ed last week that seemed to cut in a similar direction. If the old adage is that a conservative is a liberal after he got mugged, the health care version is that a liberal is a conservative who got sick.

Update: This page listing the 2004 reforms actually gives you a pretty good idea of how France's system works, if only by seeing what some of the charges were and what they've begun changing. For instance -- they never used to have primary doctors who did your referrals. You just made an appointment with a specialist of your choice. You can still do that, but now it's cheaper to go through your primary provider. This is why I chuckle when I hear conservatives waxing rhapsodic over the amount of choice in our health system. Compared to France, we're downright imprisoned.

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Comments

I looked at the page in your 'update', and I was amazed at how cheap everything was. The cost of a night in the hospital is being raised from 13 to 14 Euros? Damn.

Posted by: Neil the Ethical Werewolf | Apr 27, 2006 12:08:23 PM

Sometimes I wonder if the free market isn't faith-based.

You wonder? Medicare and the VA are both more efficient than private insurers, but try telling that to a free-marketer.

Actual facts? Free-marketers don't care about facts. Government regulation is the problem, even when it comes to things like Enron and Worldcom - theft on a massive scale made possible by deregulation.

The same people who are running to their pastors because The Da Vinci Code is making them question their presuppositions about Jesus and Christianity will never waver when it comes to their faith in the so-called "free market" system.

Yes, you read that correctly. Their faith in God is more easily shaken by a novel than their faith in "free markets" is shaken by fact after fact after fact after fact.

Posted by: Stephen | Apr 27, 2006 12:37:41 PM

Those are copays, Neil. Here in the U.S. they range from $5 to a dizzying $20 or $25.

Posted by: J Bean | Apr 27, 2006 12:38:52 PM

J Bean,

Are you on an insurance plan that only charges a copay for hospital stays? That sounds like a fantastic plan, since even HMOs charge more that $25 a night for hospital hotel charges.

Oh, and the one Euro charge for labwork and consultation? Do you have a plan that charges you less than that?

Posted by: Stephen | Apr 27, 2006 12:54:18 PM

Do I really need to make the obvious rebuttal? Because if so, America has an "unofficial death list." And, in any case, the portion I italicized notes that the following sentence simply doesn't hold true any longer.

Uh, actually, in the following paragraph I explicitly noted that that doesn't hold true any longer, and explained how the CMU works now. Did you not mention that because you missed it, or because you thought it would be more amusing to attack my intellectual honesty?

Just curious.

Still, Franks prefers our system.

Actually, I dislike both the US and French system, as I explicitly state in the post.

Sometimes I wonder if the free market isn't faith-based.

Since our system isn't actually a free-market system, your wonderings are irrational.

The post basically goes on like that, weird, quasi-truthful nitpicks that identify the same problems we have domestically, only in France they aren't a tenth so bad and cost half as much.

Did I nitpick the French system? I wasn't trying to. There weren't any wierd rants. I was just explaining the systems, and the fact that neither one was a single-payer system.

I think you're reading into what I wrote subjective meanings that I didn't intend. I wasn't trying to be critical of the French or German systems, I was just explaining how they worked.

Posted by: Dale Franks | Apr 27, 2006 1:41:45 PM

Franks also notes that the system has staggering deficits. Well, I guess so. But not as staggering as, you know, our deficits.

2005 French deficit as a percentage of GDP: 2.9%
2005 US deficit as a percentage of GDP: 2.6%

But, thanks for playing.

Posted by: Dale Franks | Apr 27, 2006 1:46:29 PM

Since our system isn't actually a free-market system, your wonderings are irrational.

Yes, of course, but are you going to dispute that much of the faith that our system must be better than the French system has a fair amount to do with the belief that it's closer to a free-market system than theirs?

Posted by: djw | Apr 27, 2006 2:02:18 PM

"Actually, I dislike both the US and French system, as I explicitly state in the post."

Here's the end of your post:

"if you posit that our only choices are A) the current system; B) a British NHS-style system, or, even worse, a Canadian one; and C) a system more like the Germans or French have, then I guess my preference, in order, would be A, C, B."

You prefer our system. As you said. As for whether or not you were intellectually dishonest on the "unofficial waiting list," I noted that you said it's ended. What was dishonest was your lack of context for it, which I helpfully added. Yes, yes, you're welcome.

As for deficits, I figured we're both talking about health care deficits, wouldn't you agree? Medicare alone has a $65 trillion unfunded liability, and while France may be looking at a couple billion in shortfall, if they spent as much on their citizens as we do on ours (healthwise), they'd have a massive surplus. As you said, thanks for playing, next time do it honestly.

Posted by: Ezra | Apr 27, 2006 2:04:07 PM

Ezra, or anyone else who knows, I'm curious how much of total health care expenses are covered by the government floor. Your post implies the figure is quite high, whereas Dale's post seems to imply a lower amount ("essentially an odd sort of state-subsidized private insurance system").

Posted by: djw | Apr 27, 2006 2:13:41 PM

Here's the end of your post:

"if you posit that our only choices are A) the current system; B) a British NHS-style system, or, even worse, a Canadian one; and C) a system more like the Germans or French have, then I guess my preference, in order, would be A, C, B."

That isn't the end of my post. In fact, the very next sentence of my post says:

But I don't like any of those alternatives.

Again, why did you leave that out?

Medicare alone has a $65 trillion unfunded liability, and while France may be looking at a couple billion in shortfall

Uh, that's not a deficit. It is a theoretical projection of possible future deficits.

That's not the same thing.

You said deficit, so that's the comparison I made. Apparently, my amazing mental powers weren't working well enough to divine that you were using the term "deficit" in a different manner than it is normally used.

Posted by: Dale Franks | Apr 27, 2006 2:13:49 PM

As for deficits, I figured we're both talking about health care deficits, wouldn't you agree? Medicare alone has a $65 trillion unfunded liability, and while France may be looking at a couple billion in shortfall, if they spent as much on their citizens as we do on ours (healthwise), they'd have a massive surplus. As you said, thanks for playing, next time do it honestly.

Can we flesh this out a bit more? Because Ezra, the above doesn't make sense. If France already has the best health care system in the world, great patient outcomes, no waiting lines, etc., why on earth would the government choose to ratchet up health care spending to match the U.S. (percentage-wise, of course)? Especially given that the French government is already running deficits of nearly 3% of GDP. It's kind of disingenuous to say, "Well, if France spent more, they wouldn't have a deficit in their health care spending!" I mean, yeah. But considering how high French marginal tax rates are already, where's that extra funding going to come from? The old-age pension fund? The unemployment insurance fund? The education budget? The French love all their social programs equally and tend to protest en masse when any one of them is threatened...

On a broader note, it doesn't make much sense to compare the "health care deficits" of the U.S. and France. You can really only measure the deficits of government programs like Medicaid or the NHS. The U.S.'s system is made up of so many different private and public components that you can't really speak of an overall "deficit" or "surplus," per se.

Posted by: Adrienne | Apr 27, 2006 3:01:56 PM

"Again, why did you leave that out?"

Because it doesn't matter. I don't like almonds, and I don't like being punched in the face. Nevertheless, I prefer almonds to being punched in the face. You even used the word "prefer" in your sentence, I've really no clue what your argument is here. As for the amazing mental powers, don't worry about it, they take time to develop.


Adrienne: I don't see what doesn't make sense. Best in the world doesn't mean perfect. The French could spend more money and -- lo and behold -- not have deficits in their health syste,. They may decide not to do that, but they could. And so long as we're comparing systems -- and Dale explicitly did so at the bottom -- arguing that this far cheaper system has budgetary shortfalls is a bit silly. Point is, when looking at the two health systems, they get more bang for the buck, and equalizing spending would kill their deficit. From our spending perspective, they basically don't have deficits, given what we're willing to invest in health care per capita.

As for the last point, agreed, that's why I used Medicare.

Posted by: Ezra | Apr 27, 2006 3:17:42 PM

I don't think either of you should have mentioned deficits, either on a governmentwide or program-by-program basis. Deficits are a funding question; healthcare is a cost-and-outcomes question.

On cost, France like most developed countries spends ~10% GDP, a nice 30% discount to US spending. Outcomes, it goes almost without saying, despite all the wine and butter, are better in France than in the US.

Off-topic, if you'd like to talk about deficits, write that article, Ezra will link, and we can all argue 'til we're blue in the face.

Posted by: wcw | Apr 27, 2006 4:51:59 PM

DJW said:

"I'm curious how much of total health care expenses are covered by the government floor. Your post implies the figure is quite high, whereas Dale's post seems to imply a lower amount ("essentially an odd sort of state-subsidized private insurance system")."

French system is 75% publicly funded:

From the OECD observer (http://www.oecdobserver.org/news/fullstory.php/aid/356):

"In its recent Economic Survey of France, OECD reports that roughly 75% of total health spending is publicly funded, 10% is paid for by supplementary insurance (mostly mutual insurers), and the remaining portion is paid for directly by patients. Supplementary insurance has expanded greatly over the past decades to eliminate co-payments and now covers about 80% of the population."

Posted by: Terry | Apr 27, 2006 5:45:35 PM

And it's also not crushing any of their major industries in the way our system has helped destroy our automakers.

If you want to start getting into effects on the larger economy, France's unemployment rate now stands at 9.5%, to our 4.7% - who knows how much of that is due to health care, but surely that should factor into any analysis.

Posted by: Floyd | Apr 27, 2006 7:17:08 PM

My wife, an American, was almost fatally injured in Germany. The interplay of different healthcare systems has been most instructive.

Believe me, our health care system sucks dead donkey dicks compared to theirs.

Posted by: Sky-Ho | Apr 27, 2006 8:59:21 PM

Thanks, Terry.

Posted by: djw | Apr 27, 2006 10:07:29 PM

Floyd -- no analysis I've ever read of France's unemployment posits health care as an even contributing factor. Indeed, the car companies have been very clear on preferring Canada's more socialized model to ours.

Posted by: Ezra | Apr 27, 2006 11:04:28 PM

What I want to know, Ezra, is why you insist on single payer, when the best examples of good health care systems you cite are two-tiered?

I'm all for universal health care, but why should the middle class and rich get government coverage when they can already get private coverage? If you think you can talk the middle class and rich out of their private coverage and into a government system, you can expect a voter backlash like 1994.

Posted by: Adam Herman | Apr 28, 2006 3:49:46 AM

Here's a Chicago Tribune editorial that makes that connection: "Critics of the European [health care] system point out that it has its downside: While the cost to workers is high, the burden is even greater on employers, who have to contribute three times as much as their employees. This can make them reluctant to take on workers in lean times, contributing to higher unemployment."

It's no surprise that car companies prefer that the government help foot the bill; it would save them money over the system they're locked into now.

Posted by: Floyd | Apr 28, 2006 11:16:51 AM

I'm all for universal health care, but why should the middle class and rich get government coverage when they can already get private coverage?

I'm not going to speak for Ezra, but he's fairly consistent on the idea of a state-based floor and a private ceiling. If you want a plasma TV in your private room, go ahead and pay for it.

To answer more specifically: the less well off benefit in many, many ways from having the more well off as part of the insurance pool.

How do you persuade people to give up their boutique insurance? Well, compulsion's always good. And that can be done, to use Nye Bevan's phrase, by stuffing the mouths of the specialists with gold.

Here's a Chicago Tribune editorial that makes that connection:

Without citation or attribution for those 'critics'. Quel mofoing surprise.

Posted by: nick s | Apr 28, 2006 12:08:24 PM

Well, a citation would have been nice, but I don't know how important it is in this case. The idea that employers who have to pay for health care will not be able to afford to hire as many workers isn't exactly rocket science.

Posted by: Floyd | Apr 28, 2006 1:24:33 PM

"How do you persuade people to give up their boutique insurance? Well, compulsion's always good"

Problem for Ezra is, the middle and upper class get a vote. And they vote in larger numbers than the poor.

Now a very basic floor you could probably get through, because basic health care is actually pretty cheap. But when I say basic, I mean BASIC, as in free checkups, free treatment of routine illness and injuries, regular testing, that kind of thing. But heart transplants and other $50,000+ medical treatments would probably be out of the question.

Posted by: Adam Herman | Apr 30, 2006 12:03:02 AM

Three phrases should be among the most common in our daily usage. They are: Thank you, I am grateful and I appreciate.

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