Friday, April 20, 2012

Universal Health Care, French Style.

I've condensed a 2009 Q & A summary of how simple coverage can be if we just allow government insurance coverage, but private medical care. It's just like Social Security and Medicare. It's stunning:

Victor G. Rodwin is a professor of health policy and management at the Wagner School of Public Service at New York University … He has widely published on the French health care system. 

NY Times; Based on data for the year 2000, France was also ranked No. 1, with the lowest rate of avoidable deaths. The United States was last, in 19th place, with the highest rate of avoidable deaths. When it comes to specialty care, the French also have ready access. The French provide higher rates of bypass surgery and angioplasty than we do.

Q: As I understand the French health care system, doctors are private, but patients are enrolled in national health insurance. Is it sort of like Medicare for all?

A: Very much so. It’s not government run but government financed. Like Medicare and Social Security, it is funded by compulsory payroll taxes with some income tax contributions. But doctors work predominantly in private, office-based, fee-for-service practices, and there is a mix of public and private hospitals. The main difference from Medicare is that the entire resident population is covered and the benefit package is more generous. Almost the entire population has some degree of private supplementary insurance, too, much like Medigap policies for Medicare.

In France there are three major plans — one for most people who are employed (77 to 78 percent of the population), a smaller one for agricultural workers (4 to 5 percent), and another small one for the self-employed (6 to 7 percent). In addition, there are some very small plans — for railroad workers, the clergy and so forth. But all of these health insurance programs operate under the same rules. Like Medicare, they can’t turn you down for preexisting conditions. They can’t terminate you if you change your job. And they can’t stop paying when your expenses exceed a certain amount.

The French do a better job of controlling health care costs than we do. They spend about half as much per person and spending accounts for 11 percent of the French gross domestic product, versus 17 percent in this country.

Q: How do they control health care costs?

A: Three ways. First, the government negotiates prices for doctors, hospitals and prescription drugs. Second, France has far fewer private health insurers, so the system requires less expenditure on administrative costs. Third, France’s investor-owned insurance sector is far smaller than the US, and its medical-industrial complex is far less powerful, so the government can negotiate stronger cost controls.

Q: Does insurance cover the entire cost of an office visit, or are there additional charges?

A: There are no deductibles. French National Health Insurance typically pays 70 percent of an office visit. A G.P. typically charges the patient 30 percent of the $35 fee, and a specialist will charge 30 percent of the $45 fee. But co-insurance is waived for all patients with serious chronic medical conditions such as asthma, diabetes, cancer, heart disease or any other medical condition requiring more than $100 per month in payments. Most physicians in private practice accept negotiated N.H.I. fees.

Q: Is there rationing of care?

A: There is no explicit health care rationing in France. There are no waiting lists for specialized hospital treatments. There is very easy access, perhaps too easy, to specialized services.

Q: Doctors in the United States complain about having to practice “defensive medicine,” is that an issue in France?

A: No, for two reasons. First, since 2002 there has been a national no-fault compensation scheme. Second, the number of attorneys per capita in France is far smaller than in the United States. The first part of the French reform created a public fund designed to compensate patients experiencing bad outcomes in the absence of fault, and to assume some financial responsibility for medical negligence. The second part of the reform created an option through which patients could seek compensation for certain serious bad outcomes under a state supervised, non-adversarial process.

I don’t know any health system about which you can’t tell a horror story that occurred to a patient. That’s why it is so important to avoid cocktail party anecdotes of health system performance and rather examine evidence in a more systematic fashion.

Q: What key lessons can the United States learn from France?

A: The French health system demonstrates that it is possible to achieve universal coverage without a government-run system that regulates how doctors practice medicine. In fact, U.S. physicians should note that their French colleagues are not constrained by private managed care insurance plans and have greater clinical autonomy. The French system also demonstrates that in contrast to some single-payer systems, universal coverage does not preclude the existence of private insurers. In France, there’s a whole private insurance sector — not enormous, but big enough — and that’s important for the insurance industry to recognize.

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