Dr. Clif Cleaveland, Commentary

Earlier this decade, the World Health Organization ranked France as having the best health-care system in the world. The study considered access and various health statistics.

The United States ranked 37th in the same survey. A subsequent study earlier this year from the London School of Tropical Medicine and Hygiene ranked the French health-care system as tops in preventing deaths from treatable illnesses.

France has the world’s third most expensive health-care system, spending 10.7 percent of its gross domestic product on health care. By comparison, our nation spends 16 percent of its GDP on health care. Every legal resident of France is required to have health insurance.

French health insurance is a blend of public and private plans. Taxes and payroll deductions support a national program, Securite sociale. This program generally pays for 70 percent of outpatient medical care. The balance is usually covered by private health insurance plans, which may be selected by employers or individuals. Families may pick from a wide variety of private plans with varying benefits.

Taxes cover at least 40 percent of the costs of the government plan. Employers and their workers generally split the 21 percent payroll deductions that are paid to Securite sociale. The government plan pays the costs for retirees as well as poor and unemployed persons. Self-employed persons contribute a larger proportion of their incomes into the national plan.

Each person selects a private physician for primary care services. This physician arranges any referrals to specialists that might be needed. Gynecologists, ophthalmologists, and dentists do not require a referral. A patient must pay at the time of service.

The patient is then reimbursed under established fee schedules by the health plans. Fee schedules are negotiated between health plans and physicians. Most hospital charges are also regulated. Although physicians may opt out of health plans with their fee schedules, more than 95 percent choose to participate.

Securite sociale pays for all of the health care costs of patients with cancer and such chronic health conditions as diabetes, emphysema, and mental illness. Cancer therapy, which includes surgery and medications, must follow national, clinical guidelines. Coronary bypass and other vital surgeries are fully covered by the government plan. In effect, benefits increase with the severity of illness.

France has established a nationwide system to oversee prenatal and early childhood health care. The care team includes nurses, physicians, social workers and psychologists. This system is geared to identify health problems early and thereby reduce complications and expenditures later.

Administrative costs are significantly reduced by a nationwide system of electronic billing and payment. A health card that is loaded with electronic data must be presented at the time of any outpatient or inpatient medical service.

French physicians earn substantially less than their American colleagues, approximately twice the average income of fellow citizens. They attend medical school at no cost. Because malpractice suits are much less common in France, health care providers pay modest premiums for liability insurance.

The French health system faces two daunting challenges. As the nation’s population ages, there are progressively fewer citizens of working age who will pay into the national system.

The rapid rise in the costs of new medications and technology strains health budgets. For example, French physicians and their patients have remarkable access to the latest chemotherapy, even experimental agents that may be unavailable to U.S. patients. Many of these drugs are budget-busters that may cost the equivalent of thousands of dollars per year. Deficits for the health care system have steadily increased in recent years.

Canada, Germany, and France have devised different mechanisms to provide care for their residents. A nation’s health care system reflects its history and social traditions. Of the three, France most closely resembles the U.S. with its suspicion of centralized control, its protection for patient choice of provider, and its balancing of societal, political, and professional demands.

I believe that each nation offers practical solutions toward providing universal access to health care for Americans. Our political leaders need to look overseas as they tackle this vital challenge.

For a more detailed and comparative review of French and American health care systems, I recommend “Differential Diagnoses” by Paul Dutton (Cornell University Press, 2007).

Contact Clif Cleaveland at cleaveland1000@comcast.net.