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April 18, 2005

Health Care: France

Because the blogs are populated by that rarest of above-ground breeds, the policy nerd, there's been a lot of talk lately about the health care structures of various other countries, how they stack up with ours, and why we lose. What there hasn't been is much information on how these other countries actually work, save for "better" and with "more government". Since I have a very peculiar idea of what "fun" is, I'm going to try and correct that. Each day this week I'll be writing a bare bones guide to another country's health system so when you're discussing say, France, you know how it works rather than that it simply works better than ours does. Speaking of France, I'm going to start with them, because they've gotten the most attention recently. Tomorrow I'll do England, the next day Germany, Thursday will be Australia, and Friday we'll do Canada. It'll be fun, I don't promise. Alright then, off we go:


Da' basics: France has a basic system of public health insurance that, as of January 2000, covers everybody in the nation. Before then, portions of the population lacked insurance. The reimbursement rates are wholly uniform, despite the fact that there are actually three health care funds, a main one covering most workers, and then one for the self-employed and one for agricultural workers.

As that hints, the health care is occupationally based. It's paid for through employer and employee contributions (much like Social Security), in addition to personal income taxes. The latter have been increasing in recent years.

The funds are private entities under the joint control of employers and unions, which are in turn supervised by the state. As might be expected, that doesn't work particularly smoothly, and there's a constant battle for authority and control. Creative tension, one might kindly call it. The funds are mandatory, no one may opt-out, and they're not allowed to compete with each other nor micromanage care.

The public system covers around 75% of total costs. Half of the rest is paid out-of-pocket and the remaining is made up by supplementary insurance companies. About 85% of the French have some form of private insurance, which pays for the various procedures and equipment the public insurance doesn't wholly cover. This of course led to inequality, so in January 2000, a means-tested public supplementary insurance program came online in order to ensure that the poor got top care.

France is the only country where access to care is unlimited. Patients can see as many doctors as they damn well please. They don't need referrals to see specialists, and there's basically no gatekeepers at all (this is going to change, recent reforms mandate a principal doctor -- a gatekeeper -- if you want full reimbursement).

The health care system is mainly under state control. The state plans out hospitals, the allocation of specialized equipment, etc. Some of this is done at the regional level, a trend which seems to be increasing. The hospitals offer about 8.4 beds per 1,000 people (America, btw, offers 3.6. Ouch.) The public sector provides 65% of the beds, private hospitals -- which operate on a fee-for-service basis -- make up the rest, and primarily concentrate on surgeries. French citizens choose which one to go to and get the same reimbursement at either. How's that for choice? Not good enough? The French also get to choose their physicians, their physicians get to choose where they practice, and there's patient-client confidentiality.

Problems: France still has class and geographical disparities in their health care outcomes. They're not nearly what ours are, but they exist nonetheless. In addition, various hospitals offer varying levels of care, health costs are rising (again, not as much as here, but still significantly), and physicians often don't feel they're paid enough for their services, leading to a number of recent strikes. As it is, French physicians only make US $55,000, about 1/3rd what their American counterparts pull in.

Yes, but are we better? Right, you say, that's all very not interesting. But how do we stack up with France? Better? Worse?

Yeah, the second one. France's health care system bodyslams us on most every metric. Beyond the beds per 1,000 stat mentioned above, France has more doctors per 1,000 people (3.3 vs. 2.4), spends way less, has 3.2 more physician visits per capita (6 in France vs. 2.8 in America, which probably accounts for the better preventive care in France), has a much higher hospital admission rate, and beats us handily on the most important measure: potential years of life lost. American women lose 3,836 years per 100,000, while American men give up 6,648 in the same sample size (yes, we get screwed). In France, the comparable numbers are 2,588 years for the women and 5,610 for the men. Still not great, but quite a bit better.

So France spends less, gets more, and does so through a public-private hybrid that's heavily, heavily public. Socialized medicine sure is scary.

A Conservative Convert to Socialized Medicine by David Burgess. Link.
OECD frequently requested data. Link.
The Health Care System Under French National Insurance: Lessons for Health Reform in the United States by Victor Godwin. Link.
The French Health Care System. Link.
French Health Care Reform: A Step in the Right Direction by Claudia Broyer. Can't find the link.

Update: Big ups to the new readers finding this post. We'll be doing different countries all week, so y'all come back now, y'hear?

April 18, 2005 in Health Care, Health of Nations | Permalink


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» Compare & Contrast: Healthcare from After School Snack
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Wow, thank you so much. This is something I've always wondered about. I'm looking forward to the rest of the series.

Posted by: Guav | Apr 18, 2005 12:49:37 PM

Ditto. Awesome entry.

BTW, you might want to include a link to this page or one similar to it for an explanation of the years of life lost statistic. Also, could you confirm that the PYLL statistics that you're gathering are measured against the same age? The reason I ask is because the link above uses a baseline of 70, whereas this one I found for Canada uses 75. I'm assuming you're gonna use the OECD for all the statistics, but just in case you don't this is something you might want to keep an eye out for.

Posted by: greg | Apr 18, 2005 1:26:48 PM

I've always thought that physician income was the biggest obstacle to getting a national health insurance system in this country. The private insurers shouldn't be a problem, seeing as state-wide insurance contracts should be very lucrative. It all boils down to convincing that behemoth -- the AMA -- that cuts in physician incomes would be, in the long run, a good thing. They'll never go for it, of course. Hippocratic oath? Apparently, this term is no longer in the AMA handbook.

Posted by: urizon | Apr 18, 2005 1:34:33 PM

merci :) this is a superb idea, and since when has learning not been fun?

Posted by: almostinfamous | Apr 18, 2005 1:35:37 PM


This a really good idea you have here.

When you posted on the French health care system last week I expressed my liking for it but suggested that pay rates may be somewhat less.

Well pat on the back to me ;-)

Do you think there's ANY chance of bringing in a system which would result in up to 2/3 pay cuts?

I don't work in the health industry so I'm not being selfish just realistic.

I also think unlimited access would be abused in the USA. After all the more doctors and specialists you see the more people you can sue afterwards if things don't go right.

You've given figures for potential life years lost - is this based only on health systems on on all factors including lifestyle/diet?

Posted by: Boethius | Apr 18, 2005 2:05:22 PM

Based on the number of physician visits per capita you cite (6 in France, 2.8 here) they seem to have 2.14 times number of visits, not 3.2 times. Did you subtract instead of divide or am I the one confused?

Posted by: LowLife | Apr 18, 2005 2:30:01 PM

You may want to take a look at Destiny Healthcare...they operate in the USA but were founded in South Africa. This was one of the pioneers of consumer driven healthcare, which MAY be a more attractive option to socialized medicine (which the French model is not entirely socialized admittidly).

Posted by: Tundra Clown | Apr 18, 2005 2:43:30 PM


This is great stuff, but you need to include at least one more health-care related policy decision. How is medical malpractice handled? What is the estimated rate of medical errors in France compared to the US?

My impression is that in order to increase the number of doctors and lower the average salary -- something that would be INCREDIBLY difficult given the strength of the medical lobby at both the federal and state level -- you would increase the rate of medical errors. If that happened, the current tort system would be totally inadequate to handle the caseload, and the jackpot effect of winning cases would result in compensation for medical errors being doled out rather inequitably. The fix is to have a no-fault medical error compensation fund, similar to the way many states and the Feds have a crime victim compensation fund which acts as an insurance mechanism for crime. Doctors and/or hospitals and/or insurance companies and/or general fund revenues would pay into the fund.

But anyway, it's important to consider how each country handles medical errors/malpractice when looking at their policy.

Posted by: Electoral Math | Apr 18, 2005 3:55:05 PM

What I wonder about is how much U.S. health care subsidizes the rest of the world, in coming up with drugs, procedures, and so on that are then copied more cheaply elsewhere. I ask because my uncle who works for the NHS was responsible for arranging cancer care in his part of the UK, and he came straight to the Mayo clinic and borrowed most of their methodology and procedures, which no doubt were developed at great cost.

Posted by: ac | Apr 18, 2005 4:34:19 PM

Thanks, Ezra, interesting post.

That stat about "potential years of life lost"--how is that calculated and what's it relative to?

Posted by: Evan | Apr 18, 2005 5:23:46 PM

I think the hospital beds per capita statistic may be somewhat msleading.... the problem in the US is regional and local - many hospitals in some places, none in others, no real logic or rhyme or reason to the distribution - gee, there's a surprise. So 3.6, while it looks bad, is also not representative of beds in, say, New York or Boston.

The second thing that jumps out at me is the cost control question mentioned above. Our system has costs that are completely out of line, and not all of those costs - indeed, the people who get the money would argue very little - can be dismissed as simply "administrative waste" that can be easily controlled in a shiny new single payer system.

This is all very interesting, and I now feel like in 3 weeks I have learned more about finding a doctor in France than I may ever need to know, but what I've learned is that a) France's system is digfferent from ours; b) the differences make it hard to develop an apples-to-apples comparison; and c) none of the information tells me what we should do about our terribly broken system. I wonder if it wouldn't be more useful - and yet more dry and less fun - to look at all the various disparities in our own system - how obtaining care differs for young professionals, the working poor, retired seniors, the mentally ill - to see how our "system" is not one thing, but many things.

I think it's too easy - and too appealing to young, cosmopolitan types, if you'll forgive the blase generalization - to look at Europe and say, "look, their health care systems are cooler too!" and miss the point that our issues are far more different and systemic. I'll enjoy the future entries, but I don't think what we don't know about Norway is the issue.

Posted by: weboy | Apr 18, 2005 5:32:53 PM

I'm interested in the costs to individuals. You mention that the system costs less - how does this translate into taxes taken from a person's pay.

Posted by: jack | Apr 18, 2005 7:18:24 PM

ac --

that's actually false. The goverment already subsidizes most health research through grants from the NIH. We pay for most of it already. Nationalized healthcare doesn't mean nationalized drug co.'s, which tend to make up the rest of the slack (even if a lot of the "a-ha's" behind the meds come from NIH research)

Posted by: Kate | Apr 18, 2005 10:16:05 PM

Lowlife - 3.2 more, not 3.2 times.

Boethius -- This is how they do the calculation (thank Greg for the link).

Electoral -- Not sure I agree. First of all, there's no reason to believe lesser pay will increase the errors. If it was $20,000 and doctors were poor, sure, but i don't think a moderate income is going to leave them fucking up more often. As for Medical malpractice, not sure what they do, but MM is a very small portion of rising healthcare costs, it's only important because Republicans are always screaming about it.

Jack -- They pay much less than we do. Of course, they pay the government and we pay private, but they pay less. Look at it this way, both France and America have X amount of health spending that must be paid for. Whether the government does it or the private sector does it, each dollar must be made up for by citizens (customers) at some point. France's system costs much, much less than ours, and so they pay less.

Weboy -- It's a good thing to do regardless. Doesn't mean we sdhouldn't look at our own problems, but we should understand other ways of doing things.

Evan -- See the link I gave Boethius.

AC -- They probably do, at least to some degree, but that wouldn't change at all. As Kate notes, most of the research for new drugs, rather than alterations of old ones, is covered by the NIH, and that'll stick around in a public system.

Posted by: Ezra | Apr 19, 2005 12:33:11 AM

An important question: how is medical education funded in France? In America, the average doc leaves school a few hundred K in debt. Don't see lots of qualified kids heading to medical school to make 55k a year with a 250k debt at the end of four of the hardest years of their lives.

Posted by: Garrett | Apr 19, 2005 1:48:51 AM

How is medical school (and undergrad study) paid for by French doctors?

If it's state-funded, that would go a long way towards helping them accept the lower pay.

The need for US doctors to pay off huge student loans would be an obstacle for us.

Posted by: Jon H | Apr 19, 2005 1:51:42 AM

French Physicians are paid less than American ones but conversely their education is largely funded by the public purse so individual doctors do not start their careers in debt to the tune of a quarter of a million dollars.

Posted by: JB | Apr 19, 2005 1:54:24 AM

Great work as always, Ezra.

From my knowledge of France's system, derived from reading, the media and a few French friends, I believe doctors may not even have the equivalent of an American "undergraduate" education. Whatever they have is by American standards virtually free, bestowed on them by the Republic.

Raw stats miss some points that may be relevant to varying degrees, but I think are telling. Until recently French doctors still did house calls. As I understood it, in some regions that was the bulk of their duties. This may still happen, and if it ended, it did so around 2000. It was one of the reasons the doctors went on strike--they couldn't keep up a full load of patients, run a modern practice and do house calls for the money they were making, at least as I heard it.

The French are also (allegedly) hypochondriacs. Fairly or unfairly, the perception is they abuse their system, particularly being over-medicated and willing to take many unnecessary tests. The need to install "gatekeepers" suggests this. While Americans with good insurance have this problem as well, the French system has shown some strain paying for it, at least in terms of pharmecuticals. It used to be the Economist's favorite complaint. I definitely can see where offering a bounty of services can create a problem of overuse, although that's not a problem in contrast to the US.

Posted by: Exile in Colorado Springs | Apr 19, 2005 3:14:50 AM

I hope this isn't too late for you to catch this, but I'd like to see you also debunk some of the myths that have developed around other nations' health care systems. The two big examples are Canada's "Busloads of Seniors" and, as someone else put it, France's "Summer of Dead Grannies." The stats are great, but the asses who seem reconciled to their own needless deaths always love vomitting up these lies whenever improving our healthcare is discussed. Of course, I'm sure you do have other things to do.

Posted by: Exile in Colorado Springs | Apr 19, 2005 3:20:43 AM

Ezra, very good post that describes the French health system as I know it (I've been living in France for thirty-odd years).

What it costs the insured person is about 11% of gross income for employ-ees; for independent workers it's a bit more complicated and expensive. Of course, employ-er payroll contributions are fairly high, which means the system comes under fire from the laissez-faire right. (There's a nonstop rolling campaign run by the right to get the notion into everyone's heads that the system is going to hit the wall any day soon and things can't go on this way, don't know if that reminds you of anything?)

Over and above the basic system, you definitely need top-up insurance, mainly supplied by mutual not-for-profit companies. The cost of this is variable, and depends for many people on what their employer is willing to offer in the way of perks with the job--so the level of health insurance comfort you experience varies with your employability (as any health insurance at all does in the States).

Garrett and Jon H : medical and dental studies are supplied by the State through the educational, rather than the health, system.

Posted by: afew | Apr 19, 2005 3:31:44 AM

It's interesting to see how different the French system is from those in Belgium and the Netherlands, with which I have personal experience.

The Dutch health-care system is insurance- and employer-based, with a "catch-all" insurance program for those with low or no income. Everyone is covered, but some insurance plans include significant out-of-pocket costs. For example, my SO pays about €250 a quarter to insure the two of us (which is 25% of the premium cost; the rest is covered by his employer); everything is covered, but there's a €900 yearly deductible. And everyone must have a primary-care physician, which must be within a certain distance of your home.

In many respects, it operates very much like an American HMO.

Posted by: vaara | Apr 19, 2005 5:52:28 AM

Can you find any data on what the primary costs of the system are? Specifically, what would be the effect on the system if the average salary for a doctor were to double?

It seems like a great system (and being the Francophobe I am, that's a pretty stark admission), but it's pretty clear that doctors in the US aren't going to take a 65% pay cut.

In the face of that, what principles can we apply to reforming health-care in America?

Posted by: TW. Andrews | Apr 19, 2005 8:02:47 AM

Exile in Colorado Springs: "France's 'Summer of Dead Grannies.'" wasn't a myth. It was estimated that between 10 and 15 thousand old people died.

I live right across the border in Switzerland, and it was a huge scandle, with the ever-morally-upright Swiss harping viciously on the French for letting it happen.

Can't say anything about Canada's Busload of Seniors, nor is it worth trying to deny that our system is utterly broken, but in any case, July - August 2003 wasn't a good time to be old in France.

Posted by: TW. Andrews | Apr 19, 2005 8:13:47 AM

Weboy -- It's a good thing to do regardless. Doesn't mean we shouldn't look at our own problems, but we should understand other ways of doing things.

My point is that we don't understand our own way of doing things, yet many people - great, thoughtful liberals around the blogosphere - confidently assert that that things can be solved simply and easily if we just do what France does.... or Holland does... or Canada does.... or... I just don't buy that a lot of people understand what it is that we do here. Understanding what others do is great, and we may learn things from it; but someone needs to break down the US systems, explain them more fully and show what works (because some things do) and what doesn't - and I don't really see anyone doing it in a deliberate, painstaking (and it would be painful) way. Until then, this can come off, I think, to non-traveled non-coastal types as yet more veuyuristic tourism, not completely relevant to how we live here and now.

Posted by: weboy | Apr 19, 2005 8:48:30 AM

The elderly who died in France in la canicule of 2003 didn't die because of poor medical care. They didn't die in hospital. They died because they lived in un-airconditioned dwellings, and weren't advised what to do to keep cool or provided resources, and weren't checked in on by family and friends. In part, this was because the French were ill-prepared for the disaster. A heat wave of such intensity and spread was as freakish and unexpected in the hexagon as would have been a hurricane. The fact that it happened during the traditional vacation month (or six weeks) didn't help, since a lot of the bureaucracy that might have ameliorated the danger wasn't in office.

It also happened because most buildings in central France aren't cooled. Even French hospitals typically lack air conditioning outside the operating wing, a fact that few seem to regret. As an energy-and-capital conservation decision, this choice is a good one, but it required an emergency canicule plan the French didn't have. As a result, perhaps unfairly, the minister of public health was sacked. In France, the government is blamed when something goes wrong and someone had to pay. But the crisis didn't have anything to do with the efficacy of the French medical establishment.

By the way, the Chicago Heat Wave of a couple of years ago would have been equally devastating here if it had lasted longer. I was at a wedding in Libertyville (a Chicagoland suburb) in early July of 1995. People were sitting in the church pews sucking on water bottles. I was worried that the wedding party was going to pass out during the ceremony. I went outside to cool off at about 2:00am that night, and it was still in the 80s.

Posted by: Brian C.B. | Apr 19, 2005 10:06:44 AM

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