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.

The Definition of Insanity

“I’ll be late,” the text said.

I was annoyed. Certainly this was an excuse to avoid chores. “Why?” I texted back, knowing full well that phones aren’t allowed in school.

No answer.

An hour later, my phone rang. I was even more annoyed. Almost nobody has my number, so when it rings, it’s either a telemarketer or a misdial.

It was school. There had been an accident. Please go to the emergency room.

We were led to a flourescent-lit room already crowded with other parents. Nobody knew anything. The panic, the angst, while waiting was terrible.

I brought my baby home a few hours later. Nothing serious; an abundance of caution. (No hospital bill, either, thank you socialized medicine.)

I thought about that day when I heard the familiar news of a school shooting. In America–where else. I can barely type for the tears, imagining those kids, those parents, desperate for another day together.

Are people not yet sick of their children being mowed down? Is that liberty?The definition of insanity  is doing the same thing over and over again and expecting a different result.

 

Burn 650 Calories in 10 Minutes

And maybe save a life. While lying down.

Give blood.

Many, many people donate blood, yet there’s still a need. I knew this, but there was always a reason why it wasn’t convenient to participate during the local blood drives. Finally my kid challenged me to do it and wanted to watch. No peer pressure is as intense as kid pressure on a parent to bring out our better angels.

So we went one morning after shopping at the market. Several volunteers dressed as big drops of blood were pleading with people at the market to walk down the block to the room where an efficient army of workers was taking donations from a surprisingly robust crowd of volunteers.

I flunked the test, though. I had run that morning (no exercise too soon before or after) and had only coffee for breakfast. I went back after a big lunch. It went smoothly, and afterward we sat at a long table of very French food: cheese, hard sausage, brioche and some industrial baked goods (Breton cookies and palmiers). Lots of juice and water. I had some cheese and brioche and palmiers and drank a lot and figured I was good to go.

We got about a block when my head started to spin. It had been decades since I’d last donated blood. My kid guided me to a bench on the street, and I felt better after a minute. But we hadn’t gone half a block when I got dizzy again. We were in front of a café and I quickly put myself onto a chair on the sidewalk. But I started to slide right off it and couldn’t stop. My kid was trying to get me up. People stared. My kid informed me that people thought I was drunk. Lovely! Some nice ladies went into the café and came out with water and sugar, and I managed to drink it, and eventually perked up enough to get around the corner to our AirBnB apartments, which were empty that weekend. I lay down and waited for my husband to come. No driving home. I would get my car later.

Now I am in the database, and two months later I got a call from the Établissement Français du Sang (French Blood Establishment) asking for more. I learned that I could take an appointment at their offices at the hospital, with no waiting and parking right in front of the door. I got my husband to drive me just in case, but I was fine.

It was even quicker, and I thought gosh, I should do this more often–well, whenever they call. The other donors clearly were regulars.

Although I was tired the rest of the day, I have to admit I felt like a million bucks the day after. I looked up information about giving blood and found out it burns 650 calories, on average, which was a sweet bonus. Especially because you need to eat something decent beforehand (the second time I had a nice protein-rich breakfast of eggs) and will eat something afterward. I do miss those American doughnuts.

Donating blood regularly also reduces the risk of cancer and heart disease, which makes up for the lack of doughnuts.

You can donate blood every eight weeks, which comes to about six times a year. You give about a liter, or a pint, of blood per donation, which can help up to three people. You also can donate plasma and platelets, which involve a longer process and which can be donated more frequently.

My dad received blood transfusions. He would complain that his “counts were down,” and that he “needed a pint,” as if he had some kind of dipstick and it was akin to glug-glugging in a can of blood like oil into a car. I can’t bring him back, but I can help somebody else.

So can you.

 

 

Urgences

We are a little too well-acquainted with the emergency rooms. The most recent visit comes after much time spent in U.S. hospitals last year (as visitor). The differences are striking.

U.S.: imposing marble lobby, with a volunteer playing a grand piano. Food court. Gourmet coffee stand emitting good smells. Carpeted halls. Rooms that look a bit like hotels if not for the high-tech control panels and machinery. Heated blankets. A sofa in the room that turns into a kind of bed for a family member keeping watch. Another hospital went for an earthy, natural décor, with lots of warm wood, and tiles and wallpaper that had grass or leaf designs. Very zen.

France: sun-filled linoleum lobby. Linoleum, in fact, is the most prevalent material. Wall-to-wall carpet is considered a germ trap in Europe. Plastic seats–no upholstery. No attempt at décor (white walls with a green accent wall, pale gray floors) except in the pediatric wing, which had animal decals on yellow walls. The emergency room at one private hospital did, however, have as decoration framed x-rays of unusual objects, which provided a distraction. It also had wood paneling. In the patient’s room: a small table, a rigid plastic chair, a very ugly lump of an armless chair that unfolded into a surprisingly comfortable bed for a family member keeping watch. A sheet but no blanket (certainly not heated) nor pillow for said family member. No food court, and the lobby vending machines are locked up after hours (i.e., after 6 p.m.).

Carcassonne’s new 496-bed hospital opened in the summer of 2014.

So far, it sounds like the U.S. is better, BUT marble lobbies don’t make a person well. And they might make one sick when the bill arrives.

On the other hand, the bill for an x-ray of a possibly (but thank goodness not) broken shoulder? Zero.

And the bill for an overnight after our kid passed out on a school outing (why breakfast shouldn’t be skipped…lesson learned)? Minors who lose consciousness are required to be kept for 24 hours of observation. Zero.

And the latest–meningitis, which turned out to be the viral kind, not the deadly bacterial kind? Until the blood test confirmed that, our kid was treated with a speed that was amazing. And kept overnight for observation. Again zero.

This isn’t to say that we don’t pay for health care. There are mandatory social charges in the form of a 6.5% tax on income of self-employed workers; salaried workers pay 0.75% and their employers 12.8% of their wages, for a total of 13.55%.

According to the Bureau of Labor Statistics, the average cost of health insurance benefits to employers was 7.6% of total compensation, but that ranged from 12.6% for union workers to 6.9% for nonunion workers. On average, employers of higher-paid workers cover a bigger share; lower-paid workers get less.

It’s hard to get an average percentage for the employee contribution in the U.S. The Kaiser Family Foundation found that average annual family coverage premium is $17,545, with employees paying $4,955 of it. And the average deductible for a single (they didn’t give family figures) is $1,077.

There are no deductibles in France.

There are co-pays, however. The full price of a doctor’s visit in France is €23, of which the government reimburses 2/3, or about €15. I suspect it’s set up that way–patients have to fork over the €23 and wait for reimbursement–to set the bar just a little higher for whether one really needs to see the doctor. You can buy supplemental insurance to cover the co-pays.

In the U.S., the average copayment is $24 for primary care and $37 for specialty care, for in-network providers, according to the Kaiser report.

In France, all providers are in-network. You get to pick your doctor, from any of the doctors in France, not from a list provided by your insurer. And no surprises coming out of anesthesia to discover a bill bigger than your annual salary because most of the doctors who touched you were out of network. Obamacare has put a cap on out-of-pocket expenses (the sky used to be the limit): $6,850 for an individual and $13,700 for a family. However, medical bills are still causing personal bankruptcies in the U.S.

Note the covered sidewalk. The old hospital had one as well. A brilliant idea, in rain or sun.

Two people I know in France have hereditary kidney diseases. One just got a transplant; the other has been hospitalized a lot but isn’t yet at the transplant stage. One thing they don’t worry about is the cost of treatment. Ditto with friends who have cancer. One quit her job–but she didn’t lose health coverage because that has nothing to do with where or whether one works.

It seems logical to separate health care from employment. And to pay for it with a tax so that those with more money pay more and so that your health expenses aren’t at the mercy of your job or the genetic lottery. For those unfamiliar with the U.S. system, the New York Times a couple of years ago ran an excellent series titled “Paying Till It Hurts.”