P1100672I’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.P1100679

40 thoughts on “Single Payer FAQs in France

  1. Great post, as ever. This is a topic we end up discussing with almost all of our American clients, who are very curious as to how France manages the health system. Having never lived in a country without affordable universal healthcare, the American system is kinda boggling to me. Like you, in 10+years, our experience of the French health system has been consistently excellent and genuinely affordable. The contrast between the calmness of a French A&E room and a UK or Australian one full of drunks and drug addicts is extraordinary.

    Liked by 1 person

    1. I can talk to people who complain about all the things their (employer captive) insurance doesn’t cover and the hassles about trying to get reimbursed, and the high deductibles (I forgot to bring up deductibles, which don’t exist here…unless you count the one-third payment). And then the same people will argue that single payer would be worse, that health care would be rationed, etc. Health care IS rationed in the U.S., based on cost.

      Liked by 1 person

  2. Yes everybody forgets that the astronomical cost of a functional healthcare system would be offset by cutting the astronomical costs of the ridiculous system we have.

    My dad is hoping that with the new Supreme Court, Obamacare lasts until his 65th birthday next summer.

    Liked by 1 person

    1. The thing is, doctors, hospital administrators, pharma executives, etc., all are wealthier than average citizens, but not nearly to the extent you find in the U.S. Those people don’t want to lose out. And also, those captive insurance programs are a big tax benefit for corporations.

      Liked by 1 person

          1. One doctor my family is friends with who is older (I think slightly under 65) and super cheap even accepts that doctors’ pay is going to go down, and it’s not like him at all. But I think the administrative bloat is a bigger burden on us than the doctors’ pay. Also, malpractice insurance premiums that doctors pay are absurd.

            Liked by 1 person

  3. Even coming from the UK with its wonderful (but creaking) NHS, I applaud the French system. I know that if I had had breast cancer while in the UK, the gaps between consultations would have been long, and it would have been me who had to make appointments with specialists. Here in France, my lump was found through the 2 yearly dispatage, at the beginning of November and biposied two weeks later. I saw the consultant surgeon, who confirmed that it was cancer & I would need surgery, she passed me on to an administrator who made all my appointments for scans etc. The final diagnosis was at the beginning of December, surgery on 3rd January and into chemo at the beginning of Feb. No waiting around, no cancelled appointments…everything on 100% paid by the state (including some non-cancer related medicines – thank you local doctor!!) I cannot fault the system. Yes, as you say, the hospitals are not fancy, but the care I received was second-to-none.

    Liked by 2 people

  4. Clear summary of how the “Sécu” works. I spent 36 years in the US before returning to my native France this summer (for good) and I can’t even begin to tell you how relieved we are: we know that we’ll never have to sell our house if a medical disaster strikes. The American system never made sense to me but most of my American friends seemed to be fearful of Government Health Care. Except those who were “lucky enough” to get ill while traveling in France, or other European countries!

    Liked by 2 people

  5. Great post. We had good experiences with the medical care there. I remember thinking the hospital wasn’t “pretty” and now it all makes sense (had to take our son in for a head injury). When our daughter was at the Sorbonne, she was briefly hospitalized and we never even got a bill.

    Liked by 1 person

  6. What about immigrants? Does the French healthcare pay for anything they need too? The U.S. has over 40 million immigrants (recorded in 2016).
    I’m all for France’s style healthcare for citizens. I never realized how fancy our hospitals were until your blog. The fact the hospitals don’t tell you what they charge for procedures or tests or stitches bother me. This would help drive costs down since they do compete (but that isn’t the subject).
    Speaking of high costs..i used to work for medical company who made defibrillators. The amount of mark up on parts was shocking. For example the thermal printer would cost $150 but we charged customers $1000.00 + $350/hour to repair. So it isn’t just our hospitals over charging. There should be a cap on the % of gains. My opinion anyway.
    I liked your blog, as usual. Very interesting.


    1. All legal residents get health care. I am an immigrant to France, after all. I pay the taxes as a self-employed person and have a carte vitale. Yes, there are some rights for illegal immigrants, with 100% of the cost covered within certain limits. As the government website says: “Access to care is a fundamental right for all.”

      Liked by 1 person

  7. It’s much the same here in Canada. I think it works. Granted, I am rarely sick, but that doesn’t matter- if someday something traumatic happens, I shouldn’t have to lose everything because of a cancer diagnosis or a bad accident, as can happen in America.

    I have the same mentality about taxes for education. I may not have children, but I don’t mind the fact that some of my taxes are going into schooling for the children of others regardless- I like living in a society where people are educated.

    Liked by 3 people

  8. Excellent post. Intelligence shines in your ability to explain this somewhat complex subject in simple terms. I wish every American could read this and understand how wasteful and unnecessarily expensive our system is. We do not need megalith health insurance companies!

    Liked by 5 people

    1. Keep in mind that most people who get health insurance from their employers are dealing with insurance cos. only as administrators. The real insurers are their employers, not the insurance companies, which I think is scarier.


  9. I would honestly move to France just for it’s healthcare system (okay, and its wine and cheese) and wish every single day it was in the realm of possibility to get out of the US.

    My husband and I have insurance through his employer but we’re both still afraid to go to the doctor because we honestly have no idea how much a visit will end up costing – the last trip when Mr Husband had a lingering sinus infection and consulted with a physician’s assistant for 10 minutes left us with a $200+ bill….and that’s WITH insurance.

    The system in the US is completely broken and I don’t see it getting any better because too many people have been led to believe that a single payer system means they’re going to be taxed to hell and beyond then end up having to wait months to get an appointment.

    Liked by 3 people

    1. If health care is paid through a tax, then it’s relative to income. So people wouldn’t pay the same amount, which really bothers some folks. OTOH, people don’t pay the same amount already. Even within a company, there can be requirements for being full-time to get health insurance, and it tends to be the lower-paid hourly workers who lose out.

      Liked by 1 person

  10. I live in the US. I’m also a nurse. I wish we had single payer in the US. So much time and money is spent on figuring out the complexities of insurance.

    Liked by 2 people

  11. Re the US system, not only is health care rationed by finances, but costs are inflated by layers upon layers of bureaucracy and paperwork that have been imposed over the last couple of decades for a “profit” system.
    Also, and I was told this by an HR exec specializing in benefits: If you have insurance, you/your plan get billed at wholesale. If you don’t have insurance, you are billed at retail. Almost all hospital bills can be negotiated; many places have someone on staff to help that way.
    But most people aren’t aware that there are ways to fight back.
    I’ve had a little bit of experience with the French system, and everything good Our Hostess says about it is so.

    Liked by 1 person

    1. The New York Times has written a lot about this–the fact that the better off you are, with good insurance (i.e., an employer who is shelling out for you) the lower the price of the procedures because the insurance company negotiations lower prices. And the more vulnerable you are, with bare-bones insurance that doesn’t cover many procedures, no insurance, the higher the price you are billed because you have no negotiating power. Yes, people can negotiate themselves, but how many are able to do that?


  12. Looking at photos of the Carcassonne hospital underwater, and worried about you, your family and your home. Hoping for the very best for you, and hoping for good news when you have a chance to give us an update.


  13. I will take time to re-read your post and do a first read on all the replies. America carries the burden of cost for ALL that present to an emergency room with life threatening illness, and that’s a lot of uninsured persons that do not pay into our health coverage. As a registered nurse on a military base here in America I can tell you that the care is great but the wait time is lengthy for specialties. When we lived in Fort Bliss Texas, the city hospital of El Paso was 100% citizens of Mexico, and refused to leave without medications provided! That is just ONE example of how our health care system cannot capture reimbursement versus the health care system in France, which requires a “card” or self pay. I know a few years ago France was ranked #1 in healthcare in the world. I have in the past researched how my husband and I could retire permanently in France, and one of the criteria is have a physical documentation of good health, capable of paying for insurance and a chest X-ray! One cannot compare France to USA due to the mere amount of patients seen per day or year here versus France. Please. You are comparing grapes to watermelons!

    Liked by 1 person

  14. Not sure how I missed this post, but I’m glad I’m catching up, even if tardily. This post is excellent — you explain so clearly and rebut anticipated arguments trenchantly. Besides the moral or ethical need to care for those who are less fortunate, you make a strong case for the rational economic benefits of a Single Payer system. And you make me so grateful that I was born north of the 49th parallel rather than south. . .It’s hard for me to understand how the U.S. can consider itself a developed country when so many of its citizens can’t afford/access decent health care.

    Liked by 1 person

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