France and U.S. Health Care: Twins Separated at Birth?
Megan McArdle Mar 6 2012, 11:10 AM ET
By way of introduction, I want to make clear that I have no particular expertise when it comes to healthcare policy. My knowledge is merely that of a layman who follows the news. I'm even well-aware that one of my esteemed co-guest bloggers is Avik Roy, who's one of the most talented health care wonks on the internet, whose work I avidly followed at his previous National Review digs. In fact, this post can be read as an invitation to Avik to enlighten me.
All that being said, from my outlook there's something that I haven't seen discussed and yet seems striking to me: how similar the French and U.S. healthcare systems are.
On its face, this seems like a preposterous notion: whenever the two are mentioned together, it's to say that they're polar opposites.
France has been called the best healthcare system in the world by the World Health Organization. And if there's something everyone in the US seems to agree on, it's that US healthcare, well, horribly sucks, although they strongly disagree about why and what to do about it.
And yet, to me, the similarities are glaring:
First of all, the French healthcare system is built on a large, highly-regulated private sector. Unlike Britain's NHS, the government doesn't own everything. Some hospitals are public, but many are private and for-profit. Indeed, there are publicly-traded hospital chains, just like in the US. Most doctors and nurses work in private practice. Even most of the ambulances are private. The sector is highly regulated and subsidized to be sure, but that's also true in the US.
Secondly, there's a crucial feature at the heart of the French healthcare system that is also at the heart of the US healthcare system--and that all US wonks hate: employer-provided insurance.
France has had a US-style employer-based healthcare system since the end of World War II, but the Couverture Maladie Universelle (literally: universal healthcare coverage), the government program that covers people who can't get insurance, was only enacted in the late 90s (ah, global macro booms). Given how tantalizingly close Bill Clinton was to passing universal healthcare in the early 90s, it's easy to imagine a parallel universe where Americans had universal healthcare before the French, again something you wouldn't guess from reading stories on French healthcare.
The way healthcare works in France, basically, as I understand it from living here (and I may be wrong about this because it gives me migraines), is that you get insurance through your employer which they deduct from their taxes. You can also buy it on the market (and don't deduct it from your taxes). If you can't get insurance, the government will pay for your treatment in a system similar to (I think?) Medicaid, ie you go to the doctor or the hospital you want, and the government will pay for it in a stingy way that incentivizes you to not want to rely on the government too much but still ensures no one is left to die on the streets. French doctors frequently grumble about CMU reimbursement rates as American ones do Medicaid/Medicare rates. Conversely, if you have a job with coverage, you can buy additional coverage and/or services out of pocket.
Some jobs have better healthcare than others: my wife works for a big management consulting firm and has very generous healthcare coverage; as her husband, I get coverage through her policy, since as a freelancer my options are mediocre.
When we had our baby, my wife and I sprung for a private clinic. We chose this clinic because it is a religious institution that provided religious services on top of medical ones, which was important to us, and only later discovered that it's one of the best clinics in Paris and