Single Payer FAQs in France

I’ve been reading news about “Medicare for all.” For people outside the U.S., it’s a no-brainer. Of course everybody gets health care. Of course the cost isn’t based on how healthy you are. Of course it’s affordable. Of course you choose your doctor.

I can only really tell you about the French system, which, in nearly 15 years of experience, has been excellent.

Helicopter landing at the hospital. Courage to whoever was inside.

Who qualifies?

All French residents get a Carte Vitale, a green chip card with your French social security number (kids under age 16 are on the card of one of their parents). The card itself doesn’t cost anything. Coverage is obligatory. If you are a tourist, however, you aren’t covered and have to pay out of pocket or get your insurance to pay. But the bill won’t be anything like what you’d confront in the U.S.

 

Emergency room waiting area. Efficient. Carcassonne’s hospital is fairly new.

Who pays?

Everybody. The government insurance covers 77% of health expenses. A further 14% is covered by complementary insurance and almost 9% covered by individuals (co-pay, if you like, but not for everything; it’s mostly for glasses and dental work). The government funding comes from employer and employee payroll taxes (50%), income taxes (35%), taxes on tobacco, alcohol, the pharmaceutical industry and voluntary health insurance companies (13%) and state subsidies (2%).

I was talking to someone in the U.S. who was turned off by single payer, saying that he didn’t want to pay in for lazy people who don’t work. Of course, there are some freeloaders in France, but the cost of keeping them healthy is nothing compared to the taxes evaded by the rich using offshore shell companies. They are the real freeloaders. But psychologically, humans pick on those with less status than us and turn a blind eye to those with more.

Also in France, there’s a list of 30 health conditions that are 100% covered–hospitalization, treatment, doctor visits, medication, etc. These include diabetes, Parkinson’s, Alzheimer’s, incapacitating stroke, cystic fibrosis, HIV, malignant cancer, etc.  A friend had a kidney transplant–something stressful enough, and at least she didn’t have to worry about the cost.

Where emergency patients get wheeled in on gurneys for triage. Not fancy.

What is this complementary insurance?

Complementary insurance covers all or most of the fees not covered by the government program. It’s voluntary and paid individually. It’s private mutual insurance, meaning it’s nonprofit. Patients lose if profits win. The average in 2017 was €688 per person annually or about €57.33 a month.

Patient room. The screens are for TV and Internet; you have to buy time.

How high are the taxes?

Employers pay 13% of salary for health care, maternity, disability and death insurance. Self-employed people making under €43,705 a year pay between 1.5% to 6.5%; over that you pay 6.5%.

In the U.S., the average worker contributions are $1,213 a year for a single person and $5,714 for a family. Worker premiums have gone up about 75% over the last 10 years, vs. about 48% for the employer share. About 80% of workers’ employers pay at least half the premium for both single and family coverage. The average cost of insurance for employers is $6,435, with a $6,000 deductible. (Excuse me, I just fainted at that deductible.)

Other view of a room. The brown column is a closet.

How does it work?

If you’re sick, you call your doctor. Around here, we sometimes can get in the same day, sometimes not. If it’s urgent, one of the other doctors in the group will take us. We don’t have many emergencies, so we usually make appointments for a week or two in advance for routine checkups. Our long-time doctor moved away, so we shopped around for a new one, trying a few recommended by different friends before settling on someone we liked a lot. The idea of in-network or out-of-network doesn’t exist because there’s just one network. While people are free to shop for a doctor when thinking about switching, the French system does require picking a primary-care doctor to limit abuse, such as how much people can shop for somebody to write them a prescription they might not need.

If you have to go to the hospital, there are no surprise bills from out-of-network doctors you never met or who worked on you when you were unconscious. Some doctors can demand a surcharge, but it’s usually in the tens of euros.

How is it different from the U.S.?

Everything is less fancy. This might be in part because we are in the sticks and not in Paris, but I saw the same thing in Brussels. It’s all nice, but not luxe. One hospital in my hometown had a grand granite entry with a grand piano, carpeting in the halls, sofas and armchairs in the rooms. Here, the hospital is brand-new, heavy on the linoleum, only one hard plastic chair per patient room.

However, granite (or carpeted–EEEWWW) floors don’t make anybody better. All that matters is that the place can be kept clean and that it’s arranged in a functional manner.

Vintage formica table in one room. Must have come from the old hospital. Or even the hospital before. Waste not.

The doctors’ offices are pretty simple, too. Always nice, but never fancy. One thing that I found unusual was that the office and examining table are in the same room. You go in, sit at the desk across from the doctor, then get undressed (no paper gowns), get examined, get dressed, your Carte Vitale is read, you pay your €25 and leave. No little exam rooms in a line where a nurse charges in for your vitals, then the doctor comes by for two minutes and disappears. I told one doctor about this, and how the little exam rooms would save a lot of the doctor’s time by not waiting for patients to undress/dress, and she was horrified. Especially with the elderly, she said, it’s important to observe how patients move as they’re dressing. She saw the U.S. system as penny-wise, pound-foolish.

French health care is of very high quality despite being lower cost. France has 3.2 doctors per 1,000 people, fewer than some European countries but more than the U.S., which has 2.5 per 1,000.  Maternal deaths per 100,000 live births dropped  to 8 in 2015 from 15 in 1990, whereas in the U.S. they rose to 14 from 12 in the same years. Check out this article about dying mothers. Life expectancy at birth is 82.4 in France, among the highest in the world, compared to 78.6 in the U.S. Infant mortality is 3.7 per 1,000 live births, vs. 5.9 in the U.S.

In addition, a number of preventive campaigns aim to keep costs down by catching problems early, including free mammograms every two years after age 50, as well as free tests for colorectal cancer.

In the lobby, a piano. Not grand. Nor is the lobby.

Isn’t it weird having the government decide what’s covered?

Well, somebody has to do it, and it’s probably better that it’s decided by society at large rather than by your employer, non? Most people don’t realize that larger companies self-insure–in fact 60% of U.S. workers covered by their employers are literally covered by their employers through self insurance. It’s called captive insurance, and it’s a way of using the risk of employee health costs or death benefits (which would be low risk if you have healthy employees) as a hedge against other corporate risks. The company sets aside a pool of money as its own insurance. It contracts with an actual insurance company to administer claims. The employer can decide what to cover or not, although the Affordable Care Act set some standards on that.

That means employers have an interest in whether you’re healthy. A few years ago, AOL CEO Tim Armstrong announced to employees that he was cutting employees’ retirement benefits because of self-insurance payouts for two “distressed” babies.

With single payer like in France, employers help pay in, but risks are spread across the entire country. There are no questions about pre-existing conditions, because participation in the system is obligatory.

While there are certainly cases of people abusing the system (I know a couple who would go for a weeklong “cure” for “arthritis” every year at a spa), for the most part nobody gets surgery for the heck of it, nobody has chemotherapy just because they can get it for free. Health care is one of those things you want to not have to need. It shouldn’t be available only to those who can afford it, certainly not in developed countries.