Health care in France gets top marks
Quality praised, even as some lament costs
By Ray Moseley
Tribune foreign correspondent
July 8, 2001
PARIS -- David Burgess, 56, an American living in Paris, describes himself as "positively a right-winger," and he came to France 18 years ago with an aversion to its socialized health-care system.
Most of all, he resented the steep price he was forced to pay for it: about $438 per month. On top of that, $384 goes out of his monthly paycheck to cover his French pension.
But in the past 2 1/2 years, Burgess' resentment has evaporated under the impact of an illness that almost cost him his life. He developed cancer of the esophagus and was told the mortality rate was about 85 percent within the first three years.
But so far he has fought it, boasts that his care has been superb and says the only out-of-pocket expense he has incurred amounted to $6.50. "I'm not sure what it was for, but I paid it," he said. "I no longer complain about my taxes."
A friend who is dean of a New England medical school told him equivalent treatment in the United States would have cost about $700,000.
"I have nothing but praise for the French system, for the doctors and nurses and the quality of care," Burgess said. "I used to think I was paying a bloody fortune, but the French system saved my life. I don't know what it is like in the U.S., but if I lived in England, where the system is not as good, I would be dead now."
The World Health Organization in Geneva rates national health systems by a variety of criteria, and on all scales France is among the world's leaders.
U.S. ranks 37th
In overall performance--relating achievement to expenditure--France ranks No. 1 in the world, the U.S. 37th. All 15 nations of the European Union, with similar systems, fare better than the U.S. in the WHO ratings--even Britain, whose underfunded system is widely criticized in Europe.
All are based on the premise that every resident is guaranteed the same quality of health care, by contrast with the U.S., where 40 million people have no health insurance.
This represents a major philosophical and cultural difference between Europe and the U.S., and whether Americans would ever accept such a concept is open to debate. A bill expanding the rights of patients in dealing with their health insurers recently passed the Senate but faces an uncertain future in the House. Former President Bill Clinton's ambitious universal health-care plan died in Congress in 1994.
Critics of the European system point out that it has its downside: While the cost to workers is high, the burden is even greater on employers, who have to contribute three times as much as their employees. This can make them reluctant to take on workers in lean times, contributing to higher unemployment.
But there is no public debate in Europe about this. People may complain about the way health systems work in practice, and governments worry about rising costs as their populations age. But the principle of universal health care is widely accepted, even though it takes an average of 40 percent of a worker's pay.
"Overall the French are satisfied with the system and want it maintained," said Edouard Couty, a senior official of the French Health Ministry. "It is very important sociologically."
Dr. May Mabro, a doctor at the suburban Foch Hospital in Paris who has treated Burgess, said there is an official list of 30 serious illnesses for which hospital patients pay nothing. The list covers all types of cancer, diabetes, heart disease and other ailments.
Same care for all
The hallmark of the system, she said, is that it guarantees "the same quality of care for all, regardless of social level or income. When people are ill, we don't look at how much money they have." The system even pays for taxis to bring people to the hospital, and take them home, regardless of ability to pay.
"I think this system is not perfect," Mabro said. "The system is sick because it is too costly. Perhaps people who can afford to pay something should do so."
Mabro said many French people feel coddled by the system and abuse it. They mistrust a doctor who prescribes inexpensive medications, she said, because they think costly medicines must be better. Generic medicines, only recently introduced in France, are not popular.
She recalled that a government TV campaign 10 years ago tried to make patients more responsible, for example urging them not to take an ambulance if they could come to the hospital in a car. "This was unpopular, so it was stopped," she said.
Likewise, Mabro said some doctors order examinations that are not necessary.
While Burgess, a copy editor for the International Herald Tribune, got into a hospital a day after his illness was diagnosed, Mabro said in many outlying towns, it may take a month or longer to gain admission to a hospital. Even in Paris some people have to wait three or four weeks for surgery, she said.
Pay for doctors
Like all the staff in her hospital, Mabro is paid by the hospital from an annual budget allocated by the government. A doctor with two or three years of practice can earn about $49,000 a year.
A Health Ministry official said such doctors can boost their incomes by up to 30 percent by seeing private patients. More senior doctors, he said, can earn about $76,000 from their hospital work.
These may seem modest pay levels by American standards, but they compare well with those of lawyers, other professionals and senior executives in France. Still, there is dissatisfaction among doctors over pay.
"We are asked to provide higher and higher quality care and more costly therapies," Mabro said. "But the budget from the state stays the same."
The French system clearly works best for those with life-threatening or long-term illnesses that are hugely expensive to treat. With 100 percent coverage of costs, no one need worry about ruinous medical bills. Even illegal immigrants are entitled to such treatment but can find themselves expelled afterward.
The Health Ministry's Couty said the system needed to be adapted to focus more on care of the elderly and treatment of Alzheimer's disease as the population ages. At present France has only one specialized public hospital for Alzheimer's patients.
Helping the elderly
Under a law taking effect this spring, the government will devote more resources to helping the elderly stay in their own homes and to give them better care if they must go into institutions. Local governments now cover the full costs of care for the elderly, then claim the money back from patients' heirs when they die. "It can be almost the entire inheritance," Couty said.
The new law will put a $42,000 ceiling on the amount the local government can extract from heirs.
In the mid-1990s, the entire social security system was $12.5 billion in the red. The government raised taxes steeply to overcome the deficit, and there was hardly a murmur of public protest. "The French are very attached to the system," Couty said.
There may be no one in France more attached to the system than that one-time skeptic, David Burgess. But even he agrees that, in at least one respect, it falls short of perfection.
"The only criticism I have is that the hospital food is absolutely disgusting," he said. "Even the doctors and nurses agree it's a national disgrace."