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Lessons From the French Health-Care System


The graph above comes from Edward Cody's overview of the French health-care system. Compared with the U.S. health-care system, the French system covers everyone, spends less, and sees its costs rise more slowly. It's a pretty impressive performance. Even Kent Conrad thinks so.

But we've worked extremely hard during this debate to ignore all of its lessons. It's a bit weird: If the French medical system developed a cutting-edge treatment that proved to be the best approach to, say, late-stage Parkinson's disease, we wouldn't dismiss it as a French treatment. We'd use it. Which is exactly what we do with deep-brain stimulation. But when their health-care system develops a better, cheaper, fairer, more effective way of structuring health-care delivery and financing, we dismiss it.

People sometimes ask what the lessons of other country's health-care systems are. The lessons are twofold. First, they're better. Second, we're stubborn.

By Ezra Klein  |  September 23, 2009; 10:57 AM ET
Categories:  Health of Nations  
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Edward Cody's article focuses on the problems in France. State coverage is becoming less generous. The role of private supplemental insurance is increasing. All in all, it sounds like the Frenchh are on the wrong track too. Fortunately they have a much better social safety net to fall back on.

Posted by: bmull | September 23, 2009 11:16 AM | Report abuse

it would be nice if the reason that we're not allowed, in our public discourse, to talk about other country's systems, was mere stubborness, but it isn't: it's xenophobia, a much more difficult problem to address.

Posted by: howard16 | September 23, 2009 11:16 AM | Report abuse

It usually seems like a combination of ignorance of other health care systems (it's easy to get caught up in our intellectual discussion bubbles and forget what most of the population actually knows - or doesn't), and "Why do you hate America?" stubborn-ness. They (and usually WE) have been brought up on a steady diet of "America is the best; America can do no wrong; America is the epicenter of progressive and power", and they tend to get defensive when that's questioned.

Posted by: guardsmanbass | September 23, 2009 11:50 AM | Report abuse

"it would be nice if the reason that we're not allowed, in our public discourse, to talk about other country's systems, was mere stubborness, but it isn't: it's xenophobia, a much more difficult problem to address."


Posted by: adamiani | September 23, 2009 12:05 PM | Report abuse

And the French system is also going bankrupt, just at a slightly slower pace than our own. Why would we want to emulate a system that is also broken? Why not try to devise a better solution?

Posted by: ab13 | September 23, 2009 12:07 PM | Report abuse

this is all fine and good but check out this link. Maybe a good chunk of the reason that the French are healthier and in turn cost less is because they're obesity rate is 9.4% while ours is more than 3x that number.


when will people (and you too Ezra) learn that costs drive insurance rates and not the other way around. If people in the US were healthier then our costs would be lower. The fact that our life expectancy is only 3 years less than France is a testament to how the US treats us when we are sick. By these obesity numbers we should be near a third world country's life expectancy rate.

Posted by: visionbrkr | September 23, 2009 12:32 PM | Report abuse

An abstract concept like American exceptionalism (We're Number One) means little I think until a moment like this when it actually has such a clear effect.

Arrogance can be cured by insight, or it is cured by experience.

Posted by: HalHorvath | September 23, 2009 12:35 PM | Report abuse


you didn't catch my sarcasm? Sorry I thought i made it obvious.

I keep hearing that we're 37th in life expectancy from all the left wing talking points that I thought this proof (which never gets talked about) would show a TRUER reason why we're 37th. Should we have universality, ABSOLUTELY. And once we do we'll still be far down the line until we get closer to the average in obesity 14.4% as opposed to 30+%.

Posted by: visionbrkr | September 23, 2009 12:43 PM | Report abuse

You are way too generous, Ezra. We're not stubborn. We (ruling class, anyway) are stupid, arrogant, yahoos.

Posted by: exgovgirl | September 23, 2009 12:57 PM | Report abuse

ha! i said to myself as i was posting, i wonder who's going to bring up the obesity defense, and visionbrkr doesn't let me down!

seriously, let's try to orient visionbrkr to the topic: the issue is why don't we even talk about other country's experiences with health-care provision and what we can learn from them? and then, as part of that, visionbrkr, people can enter the obesity defense into the record and we can have a jolly old time talking about empirical realities and determining policy based on actual evidence.

instead, we don't even get to have the discussion.

PS. you do realize that the obesity defense doesn't fly? that saying "hey, if you take out the obese people, american health-care performance doesn't look at all bad compared to other countries" still ignores how much more expensive as a percentage of gdp american health care really is?

Posted by: howard16 | September 23, 2009 1:14 PM | Report abuse

To me the missing piece of this is the detail of these aggregate numbers. It's meaningless to say it costs less without looking at why. This is why we don't listen to the vague generalities, because copying the easy parts of their system (FREE MONEY!!!) without copying the hard parts (less care, poorer doctors, healthier lifestyles, etc.) would actually end up making ours cost even more.

If we look at WHY our health system costs more per capita, there are really very few possibilities.

For example, are we getting more care than the French? Are systems such as Medicare that don't reject overtreatment causing people to spend hundreds of thousands of dollars in the last month of life? Do old folks in France spend their days going from doctor to doctor to get the latest drugs with side effects that have to counteracted by other drugs? Yet any suggestion that we should reduce that are difficult to make in our "respect for life" society.

Or, are we getting the same amount of treatment, but it costs more here? How much do they pay for a knee MRI? For a blood test? We are using a very broken third party payer system here that encourages patients to ignore the cost of the treatment they receive, instead of being frugal and choosing the best value treatments.

The great conundrum of modern medicine is that we have developed treatments that we, in aggregate, cannot afford, or would rather not afford, and spend our money elsewhere.

Posted by: staticvars | September 23, 2009 1:47 PM | Report abuse


since you're not getting my point I'll TRY to make it a little easier for you. Say we had an obesity level of not 30+% and I'm sure its grown since then but rather France's version of 9.4%. That would reduce the incidents of diabetes, heart disease and I thought everyone knew that 75% of costs are related to four diseases/conditions (heart disease, diabetes, obesity and cancer).

Let me make it SIMPLER for you. If we're not fat and we're living healthier (ie exercise and nutritional diet) then we're not going to the doctor and not incurring cost. We wouldn't be taking Lipitor by the boatload. We wouldn't be having quadruple by-passes by the millions. You don't think Obesity drives costs and in turn drives the percentage of our GDP that is spent on healthcare???

And in my view, Ezra brings up cost. I took that to mean we cost more, right? Why do we cost more, I answered it. OBESITY. If we lived as healthy as the French our costs would go down dramatically.

I'd gladly talk about other countries experiences as long as we take into account THE WHOLE PICTURE, including what drives costs. But i guess an indictment of the triple cheeseburger and its consumption in the US doesn't fit into your agenda.

Posted by: visionbrkr | September 23, 2009 1:55 PM | Report abuse

visionbrkr: "If we lived as healthy as the French our costs would go down dramatically."

How dramatically? Sure, I'd agree there would be some improvement in US numbers, but is lifestyle alone enough to account for the 100% spending discrepancy between us and the French?

I agree that lifestyle choices are part of the issue. Perhaps overall life expectancy would go up a few years, but that would still put us about even with our peer nations.

And it's probably better to look at survival rates for various diseases than life expectancy anyway. In this admittedly very incomplete list (but which include some illnesses that I don't think are related to obesity), we do better than some of our peer nations in some areas, and worse in others--which again, does not justify our vastly greater expenditures.

Overall, I think that even if one made adjustments one makes for lifestyle, other countries still manage to do pretty darn close to what we do, if not better. So we shouldn't be so hesitant to see how other nations do things.

Posted by: dasimon | September 23, 2009 3:40 PM | Report abuse


I agree. Also for whatever reason we're beholden to ALL industries that are part of the healthcare sector but for some reason only insurers are demonized. Pharma takes I would assume a much bigger cut in the US than in the rest of the industrialized nations. Doctors make from what i've read 7-10x more in the US than elsewhere (although much greater in specialists than in primary care). Hospitals I'd expect don't do that much better and insurers do better than they certainly need to. My point is that if we looked at EVERYONE that is involved and what they do in comparison to the rest of the world then we'd see a much clearer picture.

Posted by: visionbrkr | September 23, 2009 4:42 PM | Report abuse

"Let me make it SIMPLER for you."

i.e. blame dumb, fat patients and greedy doctors. Yawn.

You'd think that as a now-regular reader here, visionbrkr would be aware that most of those who followed Ezra to his WaPo digs regard messed-up healthcare, messed-up agriculture, messed-up transportation policy and messed-up urban planning as part of the same messed-up system.

Posted by: pseudonymousinnc | September 23, 2009 5:21 PM | Report abuse

In France gastronomy is taught from primary school or before. Snacking is frowned on and restaurants traditionally are closed except at meal time. Portions are smaller as well. There is an entrenched culture with proverbs, ceremony, and ritual that put a check on wolfing things down quickly while doing something else, such a walking or watching TV. The media and educational system enforce the culture continuously.

This, combined with ample public transportation and intercity rail communication help keep obesity down -- for how long is anybody's guess, since trends are toward big agriculture everywhere.

Posted by: harold3 | September 23, 2009 6:58 PM | Report abuse

ie, what do you do for a living? YAWN.

Posted by: visionbrkr | September 23, 2009 8:45 PM | Report abuse

Percent obesity (OCED)

# 1 United States: 30.6%
# 2 Mexico: 24.2%
# 3 United Kingdom: 23%
# 4 Slovakia: 22.4%
# 5 Greece: 21.9%
# 6 Australia: 21.7%
# 7 New Zealand: 20.9%
# 8 Hungary: 18.8%
# 9 Luxembourg: 18.4%
# 10 Czech Republic: 14.8%
# 11 Canada: 14.3%
# 12 Spain: 13.1%
# 13 Ireland: 13%
# 14 Germany: 12.9%
= 15 Portugal: 12.8%
= 15 Finland: 12.8%
# 17 Iceland: 12.4%
# 18 Turkey: 12%
# 19 Belgium: 11.7%
# 20 Netherlands: 10%
# 21 Sweden: 9.7%
# 22 Denmark: 9.5%
# 23 France: 9.4%
# 24 Austria: 9.1%
# 25 Italy: 8.5%
# 26 Norway: 8.3%
# 27 Switzerland: 7.7%
= 28 Japan: 3.2%
= 28 Korea, South: 3.2%

O.K., we are #1, but the UK has 23% compared to France's 9.4% and the French spend abou 25% more than the English with only slightly better results. Many other counterexamples to the obesity defense can be constructed from the above data.

Posted by: lensch | September 23, 2009 8:55 PM | Report abuse

PS I am a retired mathematician. O.K.?

Posted by: lensch | September 23, 2009 8:57 PM | Report abuse


thank you for the clarification on your employment status :-)

My simple point was you weren't hiding behind what you do like he was and continues to do.

And yes anyone (as i'm sure you know as a retired mathematician) can make statistics dance to whatever tune you want. Some stats will work in your favor and swing it one way and others won't and swing it the other way. Some with varying intensity.

I would also expect that French spend that much more than the English because the English ration more through the NHS, no?

So should we, in your opinion ration in the NHS model because outcomes are basically the same?

Does the answer change for some if I or you were the rationer vs being the rationee? That gets back to the President's debate about end of life care regarding his mother (I believe it was his mother) during the White House town hall at the beginning of the summer. He basically dodged the question if I remember correctly.

Posted by: visionbrkr | September 23, 2009 11:09 PM | Report abuse

visionbrkr: "Doctors make from what i've read 7-10x more in the US than elsewhere (although much greater in specialists than in primary care)."

I think doctors do make more in the US, but not an order of magnitude more. According to the Frontline "Sick Around The World" website, family doctors in Germany make 2/3rds of what he or she would make in the US. Gregory Mankiw has data from 1996 that US doctors make on average about twice as much as doctors in Germany and Canada. (One has to be careful about "average" and "median," though.) Then again, the profession may be more attractive elsewhere if you're not constantly wrestling with getting paid by insurance companies.

I also read or heard somewhere (can't remember the source) that doctors incomes make up about 10% of health care costs. But the Mankiw blog that says was 22.7% as of 1999.

I agree that controlling costs means looking at all aspects of the system. But as Atul Gawande's much cited piece in The New Yorker showed, there are dramatic cost disparities in the US even between communities in the same state with similar demographics and similar health outcomes, so there may be a lot that can be done just by delivering care differently.

Posted by: dasimon | September 23, 2009 11:37 PM | Report abuse

visionbrkr - Again you miss the point which was not simply that the French spend more than the English, but they they do so in spite of the fact the English have a much higher incidence of obesity.

Also the rationing of the NHS has been wildly exagerated. It is nowhere as bad or irrational as the rationing in the US based on how much money you have or on the financial requirements of a for profit insurance company.

Finally it is very annoying when someone says something that is mathematically false, and you give them the data that shows it is false, then they say you can't trust statistcs. If you can't trust the facts, what can you trust?

Posted by: lensch | September 24, 2009 8:25 AM | Report abuse

Japan appears to also be a good example (although not without its shortcomings)--spends only around 8% of its GDP (half that of the US)

Posted by: georgetown_dc | September 24, 2009 10:55 AM | Report abuse

I am not a mathmatician, and I am not retired. Couldn't obese patients in the US get a very expensive, but not ineffective treatment in the US, that they don't get in England? I am not saying they do, but couldn't that explain the aparent contradiction?

Posted by: ChristopherGeorge | September 24, 2009 1:13 PM | Report abuse

In France, in the UK, in Canada and in almost every country with government health care the majority of the population have had to get private supplemental care. The have had to give up other things to pay for it. In this country, for some reason, people think they should not have to sacrifice anything to pay for health care so the government increases the taxes to pay for it. Obama says that you can keep a plan you like - he doesn't point out that you will pay a lot more for it. That in itself is a tax increase and it is on the people who can least afford it.

Posted by: tenshi1 | September 24, 2009 3:06 PM | Report abuse

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