Health Care in Other Countries: France

New York Times "Prescriptions":

Victor G. Rodwin is a professor of health policy and management at the Wagner School of Public Service at New York University and co-director of the World Cities Project, International Longevity Center-USA. He teaches courses on health system comparisons and has widely published on the French health care system. He spoke with the blog contributors Sarah Arnquist and Anne Underwood.

BY THE NUMBERS
France

• Life expectancy: 81 years (USA: 78)
• Infant mortality: 4 per 1,000 live births (7)
• Health spending as a percentage of GDP: 11 (15)
• Percentage of health spending that is private: 20 (54)
• Doctors per 10,000 people: 34 (26)

Source: World Health Organization.

Q. In 2000, the World Health Organization ranked the French health system as the best over all in the world. Do you agree?

A. I question the W.H.O. methodology, which has serious problems with data reliability and the standards of comparison. A study I would take more seriously is one published last year by Ellen Nolte and Martin McKee in the journal Health Affairs. They examined avoidable mortality — that is, deaths whose risk of occurrence would be far lower if the population had access to appropriate health care interventions. In that study, based on data for the year 2000, France was also ranked No. 1, with the lowest rate of avoidable deaths. The United States was last, in 19th place, with the highest rate of avoidable deaths. That’s a severe indictment of our health care system in my judgment and calls attention, quite justifiably, to the high performance of the French health care system.

Q. That finding implies that the French have good access to health care. Do they?

A. On most measures, they do. They don’t do a better job of cancer screening than we do. But when it comes to timely access to primary care, the French are superb.

An important and well-recognized measure is avoidable hospitalizations. People should not end up in the hospital for failure to manage routine, controllable conditions such as asthma, bacterial pneumonia, diabetes or congestive heart failure. Based on studies with my colleagues Michael Gusmano and Daniel Weisz, the United States has exceedingly high rates of avoidable hospitalizations compared with Britain, Germany or France. Comparing Paris and Manhattan, we have 2.5 times the rate of avoidable hospitalizations that they do in Paris.

Moreover, when it comes to specialty care, the French also have ready access. For example, my colleagues and I found that contrary to conventional wisdom, the French provide higher rates of bypass surgery and angioplasty than we do.

Q. As I understand the French health care system, doctors are private, but patients are enrolled in national health insurance. Is it sort of like Medicare for all?

A. Very much so. It’s not government run but government financed. Like Medicare and Social Security, it is funded by compulsory payroll taxes with some income tax contributions. But doctors work predominantly in private, office-based, fee-for-service practices, and there is a mix of public and private hospitals. The main difference from Medicare is that the entire resident population is covered and the benefit package is more generous.

Almost the entire population has some degree of private supplementary insurance, too, much like Medigap policies for Medicare beneficiaries in the United States, to provide better coverage for certain services and to cover a portion of co-insurance.

Q. So it’s not a single-payer system.

A. That’s correct, but it operates much like one. In France, nobody has a choice of insurer for basic coverage. There are three major plans — one for most people who are employed (77 to 78 percent of the population), a smaller one for agricultural workers (4 to 5 percent), and another small one for the self-employed (6 to 7 percent). In addition, there are some very small plans — for railroad workers, the clergy and so forth. But all of these health insurance programs operate under the same rules. Like Medicare, they can’t turn you down for preexisting conditions. They can’t terminate you if you change your job. And they can’t stop paying when your expenses exceed a certain amount.

Q. If the French system resembles Medicare, does that mean that it also faces the problem of rising costs?

A. Yes, all health care systems face the pressures caused by expensive new medical technologies and prescription drugs. Since there are no enforceable budget ceilings on French national health care expenditures, annual increases tend to exceed spending targets, which in turn leads to frequent cries that the system is “unsustainable.” Nonetheless, the French do a better job of controlling health care costs than we do. They spend about half as much per person on health care ($3,200), and spending accounts for 11 percent of the French gross domestic product, versus 17 percent in this country.

Q. How do they control health care costs?

A. Three ways. First, the government negotiates prices for doctors, hospitals and prescription drugs. Second, France has far fewer private health insurers, so the system requires less expenditure on administrative costs for marketing, underwriting and managing complex reimbursement rules. Third, France’s investor-owned insurance sector is far smaller than in the United States, and its medical-industrial complex is far less powerful, so the government can negotiate stronger cost controls.

Q. But you also said the French have no choice in their plan. Americans seem to want choice.

A. The French have no choice among insurers for the basic plan. But French National Health Insurance gives them more choice of doctors and hospitals than the average American has.

Q. Does insurance cover the entire cost of an office visit, or are there additional charges?

A. There are no deductibles. French National Health Insurance typically pays 70 percent of an office visit. A G.P. typically charges the patient 30 percent of the $35 fee, and a specialist will charge 30 percent of the $45 fee. But co-insurance is waived for all patients with serious chronic medical conditions such as asthma, diabetes, cancer, heart disease or any other medical condition requiring more than $100 per month in payments.

Most physicians in private practice accept negotiated N.H.I. fees. However, in large cities and for most subspecialties, 50 percent to 80 percent of physicians have chosen to “extra bill.” These physicians must pay higher premiums for their own health insurance coverage (as subscribers of the fund for the self-employed). Most of their patients can use their supplemental policies to cover some of these additional costs. But such extra billing does create hardship for people with few resources, who forgo seeing these specialists and must therefore go to hospital outpatient departments or to health centers. That’s one of the big issues now.

Q. Are the insurance companies nonprofit?

A. All health insurance funds that provide benefits under the national plan are legally private nonprofit organizations. The companies that provide supplemental insurance are a mix of for-profit and nonprofit entities. But they represent only 8 percent of total health care expenditures. It’s a smaller industry because benefits under French N.H.I. are extensive. Prescription drugs, for example, are covered exceedingly well. What’s not covered well is dental care and vision care.

Q. Is there rationing of care?

A. There is no explicit health care rationing in France. There are no waiting lists for specialized hospital treatments. There is very easy access, perhaps too easy, to specialized services. An important characteristic of the French system is that the sicker you are, the better you’re reimbursed.

Q. What does the French system do particularly well?

A. They have great access to primary care. In addition, they make specialty care available to anyone needing it. They have excellent prescription drug coverage, and they give extraordinary choice and freedom to people to navigate the system as they see fit.

Q. What’s your the biggest criticism of the French system?

A. There is poor care coordination between general practitioners and specialists, and also between hospitals and patients who move into ambulatory care. It’s a problem for people with chronic diseases.

Q. Medical malpractice has become an issue now in the debate over health care reform in this country. How much of every health care Euro in France goes to pay for malpractice costs?

A. I’ve never seen such an estimate, but even in the U.S. this figure is much smaller than people generally believe — less than 1 percent of health care expenditures.

Q. Doctors in the United States complain about having to practice “defensive medicine,” ordering unnecessary tests just to cover any potential charges of negligence later on. Is that an issue in France?

A. No, this is not an important issue in France for two reasons. First, since 2002 there has been a national no-fault compensation scheme. Second, the number of attorneys per capita in France is far smaller than in the United States.

Q. Have the French achieved universal health care?

A. Yes, the entire population legally residing in France is covered — more than 99 percent of the population. There are always people who fall through the cracks. But they are covered under a special plan that covers people whenever they show up at the E.R., the hospital outpatient department or health center.

Q. Are the French happy with their health care system?

A. Eurobarometer, Harris Interactive and other studies of consumer perceptions have consistently reported high rates of satisfaction among the French — among the highest in the European Union and certainly higher than in the United States. Still, my French colleagues were surprised when the W.H.O. report came out, ranking their system No. 1, because they are typically critical of their system. I don’t know any health system about which you can’t tell a horror story that occurred to a patient. That’s why it is so important to avoid cocktail party anecdotes of health system performance and rather examine evidence in a more systematic fashion.

Q. What key lessons can the United States learn from France?

A. The French health system demonstrates that it is possible to achieve universal coverage without a government-run system that regulates how doctors practice medicine. In fact, U.S. physicians should note that their French colleagues are not constrained by private managed care insurance plans and have greater clinical autonomy.

The French system also demonstrates that in contrast to some single-payer systems, universal coverage does not preclude the existence of private insurers. In France, there’s a whole private insurance sector — not enormous, but big enough — and that’s important for the insurance industry to recognize.

By Anne Underwood and Sarah Arnquist
September 11, 2009

Between the Lines

Displeasure with (Hatred of) Obama (blacks) is helping conservative lawmakers (racist honkies) gain ground in those states (the former Confederacy) where skepticism about his agenda (fear of communist takeover) has fed doubts (paranoia), leading to calls for restraint (lynch mobs).

--Ironic Times

But what have the Panças to do with the Quixotes?

Well, let's to our old Places again, and sleep out the little that's left of the Night. To Morrow is a new Day. Sleep, Sancho, cry'd Don Quixote, sleep, for thou were born to sleep; but I, who was design'd to be still waking, intend before Aurora ushers in the Sun, to give a Loose to my Thoughts, and vent my Conceptions in a Madrigal, that I made last Night unknown to thee.

Michael Pollan Is Sick

More evidence that food writer Michael Pollan is a paid spokesman for the health insurance industry, or perhaps just their useful idiot, comes in today's New York Times. Pollan offers an opinion piece explaining how for-profit health insurance is key to reforming the American diet.

His argument is that new rules preventing denial of coverage for pre-existing conditions will impel the insurance industry to fight against obesity, and their power is necessary in opposing high-fructose corn syrup subsidies.

The incentive, however, already exists, and the source of profits will not change. In fact, by expanding public expenditure, the existing incentives would also expand.

Pollan ignores the fact that obesity is more an issue of poverty and sedentary work and leisure than of diet per se. He ignores the fact that the consequences of obesity (e.g., type 2 diabetes, heart disease, circulatory disease) mostly manifest at a later age, when Medicare is paying. And that suggests that since, as Pollan aptly notes, "the government is putting itself in the uncomfortable position of subsidizing both the costs of treating type 2 diabetes and the consumption of high-fructose corn syrup", a position it is already in, then it is the government that needs to resolve that conflict — for the public good, not to maximize insurance-company profits.

Pollan legitimizes some of the worst elements in this debate: the concern for private insurance companies (as if they must be accommodated in any change rather than the other way around), and the illogical distraction of "personal responsibility". But to call for empowering Big Insurance in the hope that they will take on Big Food is simply idiotic.

human rights, animal rights, vegetarianism

Who's the liar? In search of the million dollar illegal immigrant to end all health care reform

Esther Cepeda writes (click the title of this post) that it costs more to find out undocumented immigrants than to provide health care services for them, that undocumented immigrants pay taxes just as everyone else does, that many citizens are not able to document their status, and that the flu doesn't care but affects us all.

Michael Pollan in pay of health insurance industry?

Russell Mokhiber writes on Counterpunch (click the title of this post):

Michael Pollan is a professor of journalism at the University of California, Berkeley.

He’s a prolific author and speaker.

And he’s a campaigner for fresh, wholesome, locally grown organic food.

He’s the author of many books, including The Omnivore’s Dilemma.

On his web site, he lists all of his recent appearances and speaking engagements.

Missing from the list?

Pollan’s June 4, 2009 appearance before the annual convention of America’s health insurance industry lobby – America’s Health Insurance Plans (AHIP).

Title of the panel on which Pollan appeared?

“Changing American Attitudes Towards Personal Responsibility and Health.”

The personal responsibility thing is, of course, at the heart of the national debate over health insurance reform.

Are we our brother’s keeper?

Or are we not?

Pollan stepped right in it last month when he posted an item on conservative David Frum’s New Majority web site.

In it, Pollan sides with Whole Foods and against those – like Single Payer Action – who have called for a boycott of Whole Foods.

Single Payer Action called for the boycott last month the day after Whole Foods CEO John Mackey penned an op-ed in the Wall Street Journal arguing that there is no right to health care in the United States.

And that there shouldn’t be.

It’s about personal responsibility, Mackey says.

“Rather than increase government spending and control, we need to address the root causes of poor health,” Mackey writes. “This begins with the realization that every American adult is responsible for his or her own health.”

Pollan says he won’t join the boycott of Whole Foods.

“Mackey is wrong on health care, but Whole Foods is often right about food, and their support for the farmers matters more to me than the political views of their founder,” Pollan writes.

Check that out: farmers matter more to Pollan that the political views of Mackey.

How far do you want to take that Michael?

What if Mackey were a flag burner?

Or a racist?

Would Pollan say that Whole Foods’ support for farmers matters more to him than the racist views of its founder?

Or the flag burning views of its founder?

No, he would not.

But, after all, we are just talking about life and death here.

Pollan has in the past taken the view that we can’t just be active consumers.

We have to be both active consumers and active citizens – rolled into one.

And as active citizens, how can we support a corporation whose CEO believes there is no human right to health care?

Can’t afford organic foods?

Tough luck, brother.

Can’t afford health insurance?

Tough luck, sister.

Every country of the Western industrialized world recognizes a basic human right to health care.

Except for the USA.

The result:

More than 60 Americans dead every day from lack of health insurance.

In his blog posting on David Frum’s web site, Pollan says he disagrees with Mackey on health care – but then says he wants to keep for profit health insurance companies in the game.

“When health insurers realize they will make thousands more in profits for every case of type II diabetes they can prevent, they will develop a strong interest in things like corn subsidies, local food systems, farmer’s markets, school lunch, public health campaigns about soda,” Pollan writes.

Pollan might know about his tofu and asparagus.

But he needs to brush up on his health care politics.

Keeping for profit health insurance corporations in the game will just guarantee the daily carnage of 60 Americans dead every day.

As Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine puts it – single payer national health insurance – everybody in, nobody out – is not only the best option – it’s the only option that will insure everyone and control costs.

We sent Pollan two e-mails over the last couple of weeks, seeking some explanation.

As of now, no answer.

So, we don’t know what you have up your sleeve, Michael – blogging for David Frum, cavorting with health insurance executives at their annual meeting, and advocating for a health care system that keeps profit health insurance corporations in the game.

But it sure does pose a dilemma.

And it has nothing to do with being an omnivore.

[Note: Anyone who didn't until now think that Michael Pollan is a cut-throat corporatist probably isn't vegetarian. Pollan argued in The Omnivore's Dilemma that choosing not to kill animals for food actually avoids the moral choice it appears to be. I suppose he thinks that by not eating meat you're not influencing the industry to be more humane, as he is. Except, that by not eating meat, you're contributing to the demise of the industry altogether. While his "conscious" corpse-eating legitimizes the very imperative of feed lots etc. In other words, the omnivore's dilemma is that he wants his cake and to eat it, too. The Prius is still a car.]

human rights, animal rights, vegetarianism

Adverse health effects from wind turbines in Sweden and the Netherlands

Two noise surveys from Europe are frequently cited by energy industry defenders as evidence that there are no ill health effects found in people living near industrial wind turbines. The applicability of these surveys to most proposed and recently built facilities, however, is very limited. And in fact, their findings of significant annoyance at low sound levels and small relatively turbines suggest reason for concern. Annoyance from noise, by the way, is an adverse health effect, according to the World Health Organization ("Guidelines for Community Noise", 1999), as is disturbed sleep, which can lead to many physical and psychological symptoms.

The survey from Sweden is: Pedersen and Persson Waye, 2007, "Wind turbine noise, annoyance and self-reported health and wellbeing in different living environments", Occupational and Environmental Medicine 64 (7): 480-486. The survey from the Netherlands is: Van den Berg, Pedersen, Bouma, and Bakker, Project WINDFARMperception, 2008, "Visual and acoustic impact of wind turbine farms on residents", FP6-2005-Science-and-Society-20 project no. 044628. Nina Pierpont provides a medical critique of the latter study on pages 111-118 of her book Wind Turbine Syndrome. Note that none of the survey authors are physicians, and neither the design of nor the conclusions from the surveys are reliable medically.

Here, I will simply describe what these surveys found and why they are not very relevant to current debates about wind turbine siting near homes. The general aim is to minimize the increase of noise, especially at night inside people's bedrooms. The World Health Organization says that the noise level at night inside a bedroom should not exceed 30 dB(A) and that to ensure that level, the noise 1 meter away from the house should not exceed 45 dB(A). Ontario requires that the noise level 30 meters from the house should not exceed 40 dB(A).

In the Swedish survey (Pedersen and Persson Waye, 2007), the average sound level estimated at the respondents' homes was 33.4 ± 3.0 dBA. The average distance from the turbines was 780 ± 233 m (2,559 ± 764 ft), and facilities of turbines down to 500 kW in size were included.

In the Dutch survey (Van den Berg et al., 2008), only 26% of the turbines were 1.5 MW or above, and 66% of them were smaller than 1 MW. Only 9% of the respondents lived with an estimated noise level from the turbines of more than 45 dB.

With such little exposure to potentially disturbing noise, it would be surprising indeed to find much health effect. And just so are they quoted. For example, from Pedersen and Persson Waye: "A-weighted SPL [sound pressure level] was not correlated to any of the health factors or factors of wellbeing asked for in the questionnaire"; "In our study no adverse health effects other than annoyance could be directly connected to wind turbine noise".

But note that they did find a substantial level of annoyance, especially in rural areas and hilly terrain, and, as they note, "Annoyance is an adverse heath effect." And: "Annoyance was further associated with lowered sleep quality and negative emotions. This, together with reduced restoration possibilities may adversely affect health."

And from Van den Berg et al.: "There is no indication that the sound from wind turbines had an effect on respondents’ health ...".

The elided part of the sentence is: "except for the interruption of sleep".

Again, they found a substantial level of sleep disturbance and annoyance. They note: "From this study it cannot be concluded whether these health effects are caused by annoyance or vice versa or whether both are related to another factor" (such as low-frequency noise). In other words, the data are inadequate for making any statement regarding health effects (and remember, annoyance, along with interruption of sleep, is a health effect). "Annoyance with wind turbine noise was associated with psychological distress, stress, difficulties to fall asleep and sleep interruption." "From this and previous studies it appears that sound from wind turbines is relatively annoying: at the same sound level it causes more annoyance than sound from air or road traffic."

In conclusion, even in the low-impact situations surveyed in these studies (small turbines, setbacks large enough to ensure low A-weighted noise levels), health effects, particularly due to annoyance and sleep disturbance, were seen. With larger turbines and facilities and smaller setbacks from homes, adverse health effects would clearly be expected to affect more people and to a greater degree.

wind power, wind energy, wind turbines, wind farms, environment, environmentalism, human rights, animal rights