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The French health-care system is way better than our health-care system

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Frum Forum's Rachel Ryan just had her first run-in with the French health-care system, and it went pretty great:

I walked into the Centre de Santé – Réaumur’s emergency health center at noon and was admitted within twenty minutes. Ten minutes later, I was meeting with the doctor. After a thorough exam, diagnosis, and prescription, I was sent up to the 7th floor to have blood work done, simply to “verify.” The total cost of the visit was €44, plus the additional €12 I paid at the pharmacy to fill two week-long prescriptions. If I had been covered by French national healthcare, la Securité Sociale, the total cost of the hospital visit would have been €0.

Though the term “bedside manner” is completely foreign to the French, the overall experience was pleasant, given the circumstances. The doctors could not have been more attentive, the hospital was clean, and the wait was negligible, as were the costs.

Nevertheless, I left skeptical, thinking, “it can’t be this good, what’s the catch?”

Ryan spends the rest of her post trying to draw out the catch, which turns out to be that the system costs money and is funded through taxes, so taxes will rise. But the American system costs money too, both in taxes and premiums. So the correct question is whether the French system costs more money, or is growing faster. The answer to both questions is no. In fact, it's more "no" than people realize. When France's system, which spends $3,600 per person, and America's health-care system, which spends $7,290 per person, both grow by 5 percent, then the French are spending $180 more and we're spending $364 more.

I actually think that one of the difficulties in the health-care reform debate is that it's hard for people to wrap their minds around just how much worse our system is than the French system. The size of the difference makes it seem like some sort of trick. But it's not! We're just getting a really, really bad deal!

For more on the French health-care system, see this article by Edward Cody, which is also where I snagged the graph atop this post.

By Ezra Klein  |  April 7, 2010; 2:19 PM ET
Categories:  Health of Nations  
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Comments

Sometimes when I read screeds about healthcare rationing I think the Americans wish to be like the Harkonnen and have the whole world (and our whole GDP) revolve around our bizarre ailments and their treatments. There's no other explanation for it. In fact, on blogs like RedState, there's no health care spending too lavish, no treatment too ineffective, no intervention too costly for them. They want to spend it all on healthcare, because what else is there for the most powerful nation in the history of nations?

Posted by: luko | April 7, 2010 2:32 PM | Report abuse

i'd have been curious to know what the prescription was for and how the cost of it compared to what you'd pay in the US.


Posted by: visionbrkr | April 7, 2010 2:46 PM | Report abuse

Luko, you did not just use a Dune analogy in a healthcare post! Well played, sir. I wonder if Obamacare will cover fear-induced mind-killing.

And Ezra, you forgot that with our outrageous overpayments we're getting something the French don't: it's Freedom, Ezra. It's Freedom.

Posted by: MosBen | April 7, 2010 2:47 PM | Report abuse

Great post, Ezra, I've really enjoy your blog and have read it all through the HCR debates.

I would love to be able to tell Rachel (who is worried about French tax increases to cover health care) that even with a $120,000+ income, my employer and I pay more annually in insurance premiums, copays, and deductibles than my ENTIRE FEDERAL INCOME TAX BILL.

Posted by: gingles | April 7, 2010 2:50 PM | Report abuse

also she should have asked what that ER doctor made in salary annually and compared it to the average ER doctor in America. I'm thinking this ER doc wasn't making the French equivalent of $233k per year.

http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000222.html


Google is a beautiful thing.

Posted by: visionbrkr | April 7, 2010 2:52 PM | Report abuse

I think the telling point is that not one European country would trade their health care system for ours...

Posted by: srw3 | April 7, 2010 2:52 PM | Report abuse

This is great! All we need to do is convince American doctors to work for French doctors' salaries! Should be a simple and easy fix, right?

Posted by: ab13 | April 7, 2010 2:54 PM | Report abuse

@VB: we have been through this before, but I still believe that US doctors are overpaid. Your post supports that.

Posted by: srw3 | April 7, 2010 2:54 PM | Report abuse

srw3,

thank you. Will you also agree that this version of HCR does little or nothing to fix that. In fact it just exacerbates the problem by handing docs 30 million more patients with which to overcharge (although admittedly 15 million of them will be on "under-charged" medicaid.

What I want to know is how the French originally and consistently convince doctors to work for what we assume they work for over there without hints of strikes, labor unrest etc.

It can't really be that all our doctors are greedy and theirs aren't can it?

Posted by: visionbrkr | April 7, 2010 3:00 PM | Report abuse

My gut instinct is that one of the underplayed drivers of our absurd costs is the structure of medical education. We had a great French primary-care doctor when we lived in New York, but it's important to remember that her total post-secondary education was five years, followed by residency. We have a minimum of eight years, which increasingly involves years off for greater work experience before entering medical school. The cost of both undergraduate and medical degrees is far greater in the United States. The hours and demands placed on American medical residents is greater, furthermore, than on residents in other nations. It is not surprising that, when doctors finish residency in their 30s, with enormous debts, they view medicine first as a profit-making business. These doctors go into specialty rather than primary care, order more tests and treatments, both because their debts demand it of them, and because, after the never ending hamster wheel of american medical education, they feel they deserve it. There may be some positive effects of this system, by encouraging basic science medical research. But to me it seems that the only way we will actually drive overall costs down is either by creating a profession of nurse-practitioners (who basically take the place of primary care physicians), or by making it cheaper and less time-consuming to become a doctor. I'm not even sure that our process really produces the doctors who make the best decisions about care-- reading Gawande's article about the Checklist seems to strongly suggest that, in addition to all the unnecessary treatment, there is also a lot of just plain bad practice out there that can be improved. A shorter medical training with more stringent supervision of doctors might help rein some of this in.

Posted by: jacobh | April 7, 2010 3:02 PM | Report abuse

According to wikipedia, the GDP per capita of France in 2008 was $46,016. So the percentage of GDP spent on health care is less than 8%.

Whereas in the US, the GDP per capita in 2009 is $46,443. So the percentage of GDP spent on health care in the US is 15%.

So where's all the money going? Is US health care subsidizing research? Do things just cost more in the US? Is someone lining their pockets?

Apologies for mixing years, those are the figures readily available.

Posted by: billkarwin | April 7, 2010 3:12 PM | Report abuse

So, if French doctors aren't paid as much, shouldn't they be desperate to find doctors willing to work for so little? Shouldn't that result in worse patient care?

If they provide good care, which this story seems to support, as do other bits of data Ezra has posted over the years, and there are enough doctors to maintain that care, and the doctors aren't starving to death, why should I care that they're not as rich as they'd be here?

Posted by: MosBen | April 7, 2010 3:12 PM | Report abuse

"When France's system, which spends $3,600 per person, and America's health-care system, which spends $7,290 per person, both grow by 5 percent, then the French are spending $180 more and we're spending $364 more."

The 2,855,390 citizens of Arkansas spend about $3,687.97 each on health care, which is in the French ballpark of population and spending. When you throw states like Massachusetts, where 6,497,967 people each spend $7,423.08, the averages get skewed: some US states which do a great job at cost control (Utah, Virginia, etc.).

Make no mistake -- I continue to favor an EU-style healthcare system in America; that is, let each American state (like each European state) develop and implement its own system without interference from a federal authority.

Posted by: rmgregory | April 7, 2010 3:13 PM | Report abuse

Interesting that the first case study in the Cody article states that the patient didn't even know how much his bill was. Doesn't this violate your belief that we should all be busy on our gurneys doing the cost-benefit analysis of the various treatment options we have been offered as the way to control costs? I wonder how the French manage that?

Posted by: PEHodges | April 7, 2010 3:28 PM | Report abuse

@MosBen: "why should I care that they're not as rich as they'd be here?"

It's not that you should care how rich doctors are. But you start with what you have, and what we have is a bunch of doctors and hospitals making a lot of money. We can't just magically cut their pay in half.

Posted by: ab13 | April 7, 2010 3:29 PM | Report abuse

@VB: I agree that cost control is not as big a part of this round of HCR as expanding coverage. Are doctors here, greedier than in Europe? Doctors here are taking all they can get here, in good capitalist fashion. I bet if Europe had an organization as powerful as the AMA (especially in the post WWII period to about 1990) basically dictating health policy to the government, they would be getting more for their services.

Posted by: srw3 | April 7, 2010 3:46 PM | Report abuse

Medicare in 2008 cost $600B to cover 45M people, which works out to over $13000 per person- and then add in an extra $1000 for premiums. Whatever we do, that's the opposite of the right answer.

Looking at per incident cost to the consumer, as Ryan's piece does, misses the overall cost picture, and picks an unrepresentative sample treatment. A side by side cost comparison would be instructive, although subsidies make it hard to measure.

Looking at the overall numbers, as Klein does, misses the underlying health condition and treatment selection differences. US 30% obese, France 9% obese is a good place to start digging.

Could it be, that we are simply buying too much healthcare? It is too easy to spend from our common pool of borrowed money?

Posted by: staticvars | April 7, 2010 3:48 PM | Report abuse

@ rmgregory : Its silly to compare the money spent when france has universal coverage and arkansas has 19.2% OF THE PEOPLE INCLUDING 24% OF ADULTS UNINSURED. Talk about straw men...

Posted by: srw3 | April 7, 2010 3:51 PM | Report abuse

Ok. Now why don't you explain how we get there from here.

Posted by: ostap666 | April 7, 2010 3:55 PM | Report abuse

staticvars,

I thought of the obesity issue as well (as we all have gone round and round in this cost issue comparison for at least the last year) but chose not to. Glad you did ;-)

Posted by: visionbrkr | April 7, 2010 4:00 PM | Report abuse

@ab13: well we could stop the increases in charges by doctors and hospitals until the rest of us catch up...

Posted by: srw3 | April 7, 2010 4:02 PM | Report abuse

@ab13: well we could stop the increases in charges by doctors and hospitals until the rest of us catch up...

Posted by: srw3 | April 7, 2010 4:02 PM | Report abuse


wait, won't the doc fix that the Dems are about to propose just make that problem WORSE.

(ya I know Republicans have been pushing it off too but remember i don't care about political parties)

Out of one side we say stop the increases but out of the other side we say "let's give them MORE".

Well, which is it?

Posted by: visionbrkr | April 7, 2010 4:12 PM | Report abuse

Let's not forget Singapore either. 3% of GDP spent on health care, 6th best health care in the world, per the WHO (including lowest infant mortality rate and a whole year of life expectancy better than France).
What's the magic?
Simple combination of mandatory health savings accounts, published prices, catastrophic care insurance, and private providers. It would be a short trip from our plan to theirs.

Of course, all of the same caveats apply, but there is no reason to assume that a plan more like the French plan is the only way to improve our health care. In fact, a more capitalist system may provide better results in the long term.

Thinking in the very long term, only in the vague, hypothetical sense in which Klein accused Lieberman of killing people, does advocating more spending now, at grossly unsustainable levels, make us culpable for the future deaths that will inevitable result from the day of financial reckoning?

Posted by: staticvars | April 7, 2010 4:26 PM | Report abuse

Just three weeks ago, my wife and I were in France with our nine-month-old. When our daughter developed a 104º fever, we stopped by a local pharmacy to ask for advice. They were WONDERFUL, and after talking through her symptoms, recommended we see a local pediatrician and gave us a phone number.

We called the number from our hotel at 5:00 pm, hoping we could still catch the front desk to make a Saturday or Monday appointment. Instead, we found ourselves talking directly to the pediatrician. She told us that Saturday was 'impossible,' but that she could see us that same night. Two hours later, at 7:00pm on a Friday night, with no prior appointment, the doctor was prescribing antibiotics for an ear infection. At the end of the appointment, we paid her 55 Euro personally (no office staff to be seen) and left. Stopped by a pharmacy on the way home and picked up a 10 day supply of antibiotics for 21 Euro. Our daughter was feeling better by the next day.

We have great Kaiser coverage here in California, but the French system really blew us away.

Posted by: jeremyincalifornia | April 7, 2010 5:03 PM | Report abuse

billkarwin,

Most reports I've seen suggests France spends 10-11% of GDP on healthcare (still a lot better than the U.S.). The $3,600 is probably in purchasing power parity dollars (basically adjusts the exchange rate for cost of living differentials), which compares better to the purchasing power parity GDP per capita of France, which in 2009 was $32,900.

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2004rank.html

While we pay more, the U.S. tends to get pretty strong results in terms of things like cancer treatment/screening, preventing deaths from heart attacks - things most people really care about when it comes to health care. On the flip side, we screw up things which should be (relatively) easy to fix, such as hospital infections.

http://repository.upenn.edu/cgi/viewcontent.cgi?article=1012&context=psc_working_papers

staticvars,

I think that failing to focus on the Singapore system was a huge lost opportunity from the perspective of both Democrats and Republicans. There is a lot for each side to like in that system, or one that is similarly structured. A single payer catastrophic system with mandatory HSA contributions is a great way of combining liberal and conservative ideas. Oh well. Such is life.

Posted by: justin84 | April 7, 2010 5:05 PM | Report abuse

While in a hotel room in Copenhagen I once suffered severe abdominal cramping. I called the Front Desk and asked for a doctor. No more than 3 minutes later, a doctor arrived (and injected me with muscle relaxant).

"How did you get here so quickly? I asked.

"I'm on duty riding around the city in case of an emergency call," he said. "We have a number of doctors driving around 24 hours a day."

"What do I owe you? I asked.

"Nothing," he said. "In Denmark, health care is free."

Friends visiting Australia, Canada, and England have had similar experiences with socialized-medicine-for-all.

Those friends and I were awakened to the realization that American Exceptionalism does not always mean "in a good way."

Posted by: fredbrack | April 7, 2010 5:36 PM | Report abuse

@staticvars:

Medicare covers the population that requires the most health care (seniors). End of life health care is rediculously more expensive than any other time in life so it's no surprise it's more expensive.

Posted by: lol-lol | April 7, 2010 5:40 PM | Report abuse

The trouble with those studies that show the U.S. spending more per capita on healthcare and getting worse outcomes than countries that offer socialized healthcare is that they don't compare apples to apples. If you throw out the enormous amount of money we spend on R & D for new drugs and medical devices in this country and just look at medical services to individuals the U.S. is comparable to European countries. I guess we could spend the same amount of money on R & D as European countries, but then I you could also say bye bye to new life saving drugs. As a matter of fact Europe and Canada with their drug price controls uses the U.S. as their medical research arm, getting all the benefits with no costs to themselves. The U.S. also has about the same rate of medical inflation as they do in Europe.

Also, the way you count medical outcomes has a lot to do with how you stack up from one country to the other. For example the U.S. has always been castigated for it's lousy infant mortality numbers compared to Europe. However in some countries an infant who dies shortly after birth is not counted in the infant mortality figures whereas in the U.S. they are. There are various other examples of this type of accounting manipulation. The U.S. actually has vastly better outcomes for treatment of cancer and heart diseases than Europe.

How about long waits for elective surgery? In socailized medicine countries that's a reality. In Canada the average wait for dialysis access is 62 days and in the U.S. its 16 days. Shouldn't you add a dollar cost to that wait?

By the way nothing is free. The article above talks about how cheap it was in France to get perscriptions filled etc. But I hate to tell you somone is paying for that cheap medicine and it's the French taxpayers. If everyone in this country is willing to accept huge tax hikes and perpetual 10% or more unemployment then we could have the same type of system. You would also have to accept big brother watching your every medical move and standing over you scrutinizing every medical purchase, controlling every aspect of you and your families healtcare decisions. I doubt people in this country would enjoy that type of big government system but who knows a lot of people in this country are sheep that just go along with whatever their leaders tell them is best. I mean they voted for Obama in 2008 didn't they?

Posted by: RobT1 | April 7, 2010 5:42 PM | Report abuse

@ RobT1

In Canada the average wait for dialysis access is 62 days and in the U.S. its 16 days. Shouldn't you add a dollar cost to that wait?

What kind of dollar cost is there for people who die or go into medical bankruptcy (subjecting them and their families to psychological and physical stress) because they can't afford dialysis?

" I guess we could spend the same amount of money on R & D as European countries, but then I you could also say bye bye to new life saving drugs. "

Fact: most basic research is paid for by the govt through NIH and subisidies to universities (no tax etc.). Drug companies get huge tax breaks to fund applied research at universities that they turn around and sell, so the govt subsidizes this as well.

" As a matter of fact Europe and Canada with their drug price controls uses the U.S. as their medical research arm, getting all the benefits with no costs to themselves"

Hey I am all for drug price controls here too. No need to subsidize Europe and Canada.

"The U.S. actually has vastly better outcomes for treatment of cancer and heart diseases than Europe."

Only for people that have very good insurance or are poor enough to get medicaid. If you can't afford the treatment or you don't want to go into medical bankruptcy, it doesn't matter how good it is...

Posted by: srw3 | April 7, 2010 5:57 PM | Report abuse

@loi-loi

25% is spent in the last year of care. That seems like a waste. If we live 13 yrs, on average, on Medicare, at current levels that would be $182,000. 25% would be around $45,000 in the last year, which still means an average of around $11,400 for the other 12 years. That's sorta silly math, but Medicare simply can't hold down costs.

If you want to attack costs, increase supply (which means fighting the AMA to get our doctor per capita ratio up to French levels) and decrease demand while optimizing for value (which means let people spend their own money for most services).

Posted by: staticvars | April 7, 2010 7:14 PM | Report abuse


I think you have to be careful with the cost comparison only argument (which this
post and Rachel's actual experience isn't)
because it just plays into the skeptics' argument of "Sure, and don't do the heart-valve replacement surgery at all, and save a whole pantload of costs..." Especially in a country (ours) where 'quality' is measured by how much money you spend on something and of course we only want the 'best'.

Posted by: dcunning1 | April 8, 2010 12:09 AM | Report abuse

The French government pays two-thirds of the physician's social security taxes (about 40% of income). I'd be happy to earn a lot lower gross, if I could have a 25% tax credit in return.

staticvars: It's not the AMA that controls the supply of new doctors in the U.S. It's really the state legislatures that control the number of American medical schools that supply about 75% of the yearly crop and the federal government that controls the number of graduate medical education openings and J-1 visas. You needs to take the fight to your state capitol and D.C.

Posted by: J_Bean | April 8, 2010 12:27 AM | Report abuse

J_Bean's reply to staticvars about the AMA is correct as far as it goes. There's a lot more to it though. Increasing Med Schools and GME slots won't improve matters because US Med Schools overproduce specialists and underproduce Primary Care Docs.

France's Physician workforce has a higher proportion of primary care providers, which restrains costs. (There's also a lot of difference between French Med Education and US, especially how much it costs.) As long as the US Med Schools churn out specialists, increasing physician supply per capita will only increase costs and without improving quality of care.

Posted by: steveh46 | April 8, 2010 4:17 PM | Report abuse

What about cancer and heart attack survival rates? In other words, what if you have an illness that requires more than a doctor visit and a prescription?

Posted by: kingstu01 | April 8, 2010 6:44 PM | Report abuse

"In other words, what if you have an illness that requires more than a doctor visit and a prescription?"

France has lots of hospital beds (more per capita than the USA) and the French tend to use them.

Looking at mortality rates, you're much less likely to die of a heart attack in France than in the US, but that could mean you're simply less likely to have a heart attack not that you get better care if you have one. Likewise, you're slightly more likely to die of cancer in France than the USA, but smoking is much more prevalent.

Cancer survival rates depend on which cancer you look at. (This is also distorted by lead time bias.) See the graphs on page 11 of this if you're really interested. France is comparable to the US, there's not a big difference in cancer survival.
http://v1.theglobeandmail.com/v5/content/pdf/CONCORD.pdf

Posted by: steveh46 | April 9, 2010 10:08 AM | Report abuse

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