Paul V. Dutton: France Reformed Health Care in Tough Times; Why Can't We?





[Paul V. Dutton is executive director of the Interdisciplinary Health Policy Institute and professor of European history at Northern Arizona University. He is author of "Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France" (Cornell, 2007) and "Origins of the French Welfare State" (Cambridge, 2002).]

...Let's take France, whose health care ideals are probably most similar to our own. The French share Americans' disdain for any restrictions on patient choice of providers; they won't stand for waiting lists like the British and Canadians; they see almost exclusively private-practice physicians for ambulatory care; and they want everything their doctor prescribes covered by their insurance, including multi-day hot springs visits. In short, the French have never stood idle if their government threatened to come between them and their doctors.

So how, then, did a centrist French government in 1930 succeed at passing health care reform during the Great Depression with proto-fascists and communists sniping respectively from the right and the left?

First, doctors were key. France's doctors were politically powerful and could have stopped reform dead in its tracks, as the AMA did in the US of the 1930s. The difference: French reformers purposefully rallied doctors to the reform bill by bolstering physicians' power over medical decision-making, protecting everyone from the vagaries of insurance. People loved it....

What about insurers? France's first major legislation of 1930 stood on a grand bargain with France's private health insurers. They dropped their opposition to government-mandated insurance for industrial workers because the reform cast private insurers as the main vehicles though which premiums would flow. What we today call a "public option" was only necessary in regions where private insurers proved insufficient. From the French point of view, the Senate healthcare reform bill follows a well-trod historical path.

It's also critical to understand that France's healthcare system did not have a Big Bang. Instead, several governments led by different parties added to its depth and scope. In the mid-1930s, a socialist-led government brought farmers and agricultural workers into the system. After the Second World War in 1945 a center-right leader, Charles de Gaulle, spearheaded the creation of a large public insurer, Securite Sociale, resulting in what we would recognize as a Medicare-for-all system. Yet de Gaulle also went out of his way to assure the financial health of a competitive private health insurance industry, which today covers the French citizenry against risks and co-payments that are not covered by Securite Sociale. The self-employed joined the system in the 1960s. But not until 2000 did France achieve universal coverage. The lesson here is that we have a long road ahead of us, and that a mixed public-private system is what will please most of the people most of the time.

France's health care system is widely popular and was ranked as the best in the world by the World Health Organization in 2001 because of its universal coverage, responsive healthcare providers, patient and provider freedoms, and the health and longevity of the country's population. The United States ranked 37th. A more recent 2008 Commonwealth Fund study looked at how well healthcare in the world's 19 leading industrialized nations helped their citizens avoid death from maladies that shouldn't kill them, e.g., hypertension, appendicitis, cervical and colon cancers. Again, France came in first. The United States ranked 19th....



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