Tuesday, June 12, 2007

What Can We Learn from France About National Healthcare?

I asked correspondent/author John Kinsella, a resident of France for many years, for an "on the ground" account of that nation's healthcare system.
I think you'll find his comments most interesting, as they relate to our own debate on how to provide affordable healthcare to all.

Frequent contributor Michael Goodfellow, whose own practical and insightful essay on the subject can be found in the Readers Journal sidebar to your right, sumbitted two story links on the same subject.

The reason I asked Mr. Kinsella for a report is that we hear a great deal about the national health care systems in Britain and Canada, but very little about France's, which is an entirely different model than either the U.K. or Canada.

Here is Mr. Kinsella's commentary:

"If you were to question the average French man or woman’s opinion on their country’s health system you would no doubt be met by a deluge of criticism. Besides the fact that criticism of the country’s institutions is a national pastime, this is a rather curious attitude, since by international standards the system is judged one of the world’s best according to the World Health Organisation after that of Sweden, Finland, Norway and Japan, with the United States in the 14th position.

Any even superficial examination of a health system is extremely complex, thus it is difficult for observers to provide a rational analysis of so vast a structure, which in the case of France absorbs 10.6% of the country’s GDP, and which is influenced by multifaceted political and economic forces that come into play together with the demands of the general population.

It is evident that today, more than ever in history, health is the first priority of a nation for its population after peace, food and shelter. This is due to universal education and higher expectations, including that of life expectancy.

Healthcare is the right of every man, woman and child, and the right to health protection features in Article 11 of the preamble to the French 1946 Constitution. In addition legislation introduced in 1999 ensures the coverage of 99.9% of the country’s population.

Thus every individual, even the most modest citizen has access to instant medical care, whatever the degree of need and for as long as necessary, whether he is insured or not. It is considered a fundamental right and no person can be refused access to care.

The consequence is that any attempt to reform the generous system is instantly seen as some kind of insidious plot to reduce healthcare, often resulting in strikes and demonstrations.

In 2006 France stood at the top of the Euro Health Consumer Index, followed by the Netherlands and Germany. So the question that remains is why do French people criticise their system? The answer is that the demand for healthcare is endless; today for the slightest cold or sprain the average citizen runs to his doctor, who will refer him to a specialist, who will often propose costly treatment, when in fact old fashioned recipes would probably do the job in many cases.

Cost has become a nightmare. In 2000 France ranked number one in the world for health care, and in 2005 the country’s national health expenditure stood at €181 billion or 10.6% of gross domestic product, thus ranking France fourth in the Organisation for Economic Cooperation and Development countries, behind the United States (15.3%), Switzerland (11.6%) and Germany (10.9%).

The ongoing question is the cost and sustainability of the system, as France’s health system is institutionally complex, which leads to tensions between the state, health insurance funds and providers. The challenge of the new president, Nicolas Sarkozy is how to improve the relations and clarify the responsibilities of the key actors in the system, he has also promised to reform the system, which is a monumental task.

The principal political problem is therefore reform and cost control without reducing the quality of care, which is a daunting task for any politician.

According to the French authorities the health system is based on a national social insurance system, which is complemented by elements of tax based financing and complementary voluntary health insurance. The system is regulated by the state and statutory health insurance funds. The state sets the ceiling for health insurance spending, approves an annual plan for health and social security.

The statutory health insurance system is composed of a general scheme that covers about 84% of the population, followed by the agricultural scheme covering farmers and their families equal to about 7 % of the population. Then there is the scheme for those self-employed that covers another 5% of the population, and in 2004, a specific insurance fund was established to cover dependent elderly persons. Finally there is the universal health insurance coverage scheme established on the basis of residence in France introduced in 1999.

The French health system is noted for its high level of freedom for doctors and choice for patients, pluralism in the provision of health services, easy access to health care for most people is general, as is the absence of waiting lists for treatment that have become a serious obstacle to healthcare in Great Britain for example.

The French system is pluralistic since private and public structures coexist side by side. Patients choose their practitioners and freely access the different types of hospitals.

However, one of the sensitive questions constantly raised by different parties is the abuse of this very generous system, and abuse there is in all forms, both from the providers and those cared for. Nothing prevents a French person from seeing several doctors and specialists in the same day, his costs are covered at almost one hundred percent by the health insurance system (perhaps with an almost negligible surcharge), since the health insurance system established in 1945 offers all French citizens equal access to healthcare, regardless of income.

In 2005, the health insurance system covered 77.1% of health expenditure, whilst supplementary insurance bodies covered 12% of the remaining share, households 8.7%, and central and local government 1.3%.

The conclusion is that any such system cannot offer endless healthcare without some kind of limitation, reform is needed without refusing aid to those in need, but what kind of reform?"

Thank you, John, for an excellent precis of an extremely complex subject.

Michael Goodfellow sent in this story critiquing Michael Moore's latest film, Sicko, which relates to the French as well as the British model:

Sicko or Wacko?

"Moore calls the French system 'free,' convieniently ignoring the 13.55 percent payroll tax, a 5.25 percent income tax, and additional taxes on tobacco, alcohol, and pharmaceutical company revenues that fund the system. (Despite the high taxes, the system is running an €11.6 billion annual deficit.) The French system is not even free in terms of what patients pay. Its patients pay high copayments and other out-of-pocket expenses, and physicians are able to bill patients for charges over and above what the government reimburses. As a result, 92 percent of French citizens have private health insurance to complement the government system. Yet there remain shortages of modern health care technology and a lack of access to the most advanced care."

Michael also submitted this report on long waits for care in the U.K.:

Waiting list crisis as NHS cuts costs:

"The 18-week target, set in 2004, is widely considered to be among the most ambitious of the Government’s aims for the NHS. A baseline estimate published in December suggested that 35 per cent of patients across the country were treated within this time.

At that time up to a quarter of patients needing operations such as hip or knee replacements were estimated to wait between one and two years for surgery, with a small number waiting longer than this. The figures showed that most specialities treat between 30 and 50 per cent of inpatients within 18 weeks. In trauma and orthopaedics the figure is only 20 per cent. The Government has set an interim target of 85 per cent of admitted patients and 90 per cent of nonadmitted to be treated within 18 weeks by March next year."

Michael's comments:

"18 weeks is an astonishingly long time to be sitting around waiting for surgery! And this was for "inpatients"! So these people are already in a hospital, and waiting 4 months for treatment? Worse in a "trauma and orthopaedics" wards? Am I correct in thinking of accident victims warehoused for months before they can get corrective surgery?"

One would hope not, but it's in our interests as a nation to find out as much as we can about the real-world practicalities of alternative systems before making ideology-based decisions pro or con.

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