New York Times "Prescriptions":
Dr. Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor of The New England Journal of Medicine. A longtime critic of the pharmaceutical industry, she has called for an end to market-driven delivery of health care in the United States. She spoke with freelance writer Anne Underwood.
Q. President Obama hopes to increase the number of Americans with insurance and to rein in costs. Do you believe any of the plans under consideration by Congress will accomplish those goals?
A. They won’t, and that’s the essential problem. If you keep health care in the hands of for-profit companies, you can do one or the other — increase coverage by putting more money into the system, or control costs by decreasing coverage. But you cannot do both unless you change the basic structure of the system.
Q. Segments of the health care industry — pharmaceutical companies, for instance — are promising to cut costs.
A. It’s not going to happen. These are investor-owned companies. Their fiduciary responsibility is to maximize profits. If they behaved like charities, heads would roll in the executive suites.
Q. But what about market mechanisms for reducing costs? Wouldn’t the public option, for instance, provide competition for the insurance companies?
A. Theoretically it would, but I doubt the public plan will pass. Industry is lobbying against it, and the president has not said this is a “must.” Even if it does pass, I’m afraid the private insurance industry will use their clout in Congress — and they have enormous clout in Congress — to hobble the public option and use it as a dumping ground for the sickest while they cream off the young and healthy for themselves.
Q. How? Won’t insurance companies have to cover all applicants regardless of health status?
A. It’s hard to regulate an enormous industry without setting up a bureaucracy to oversee it. That’s very expensive and creates a whole new set of problems.
Q. How about the individual mandate? Wouldn’t it reduce costs per capita by bringing in young, healthy people who are currently uninsured?
A. No. In Massachusetts [which enacted an individual mandate in 2006], there is no real price regulation. Essentially what the mandate does is say to people, you will go into this treacherous market and buy insurance at whatever price the companies choose to charge. In effect, it’s delivering a captive market to these profit-oriented companies.
Q. Are people at least getting better health care in Massachusetts now?
A. Massachusetts already spends one-third more on health care than other states, and costs are rising at unsustainable rates. As a result, they’re chipping away at benefits, dropping beneficiaries and increasing premiums and co-payments.
Q. Then what’s the path to meaningful cost control?
A. The only way to both control costs and have universal comprehensive coverage is a single-payer system — a nonprofit, single-payer system. Nothing else will work. All other advanced countries have some form of a single-payer system, and they pay less than half as much per person as we do. We should be asking, why is that so? It’s not because we provide more basic services. We do provide more tests and procedures for those who can pay, but not more basic services — and we don’t cover everybody. So why is it so? We are the only advanced country that delivers health care in a system that’s set up to generate profits, not to provide care.
Q. If a single-payer system isn’t feasible politically, aren’t the current proposals at least better than doing nothing? Isn’t half an aspirin better than none?
A. I think not. As costs continue to soar, people will not say, “That didn’t work. Let’s try a single-payer system.” Instead, they’ll try to pay for the costs in piecemeal ways, by increasing co-pays and deductibles, by limiting services, by making the system less equitable and less comprehensive. I’m afraid the lesson they’ll draw is that universal care is impossible.
But I’m not convinced that getting a single-payer system now is politically infeasible. The public would be happy with Medicare for all. Polls have shown that the public loves Medicare. The problem isn’t the public. It’s Congress, which caves in to special interests.
Q. If Congress is reluctant to cut out the insurance companies, is that partly because they, like the major banks, are too big to fail?
A. A nonprofit, single-payer system would lead to job losses in this sector, which constitutes 17 percent of the economy. But what about the other 83 percent of the economy? They’re being bled to death. Businesses can’t compete globally because the cost of providing coverage to their workers is so exorbitant. Whatever loss of jobs you might see would be more than offset by benefits and job gains in the rest of the economy.
[As for the insurance companies,] you could introduce the program incrementally. You could do it state by state. Or probably better, you could do it decade by decade. Medicare kicks in at age 65. In the first stage, you could take it down to 55. Between 55 and 65, people are vulnerable. They’re losing jobs, losing health care. They’re starting to have more medical needs. After a few years, you could drop it to 45, then 35. It would give insurance companies time to adjust.
Q. But Medicare is already hugely expensive. How can we afford such a plan for everyone?
A. Medicare costs are rising at an unsustainable rate because care is provided in a profit-maximizing system. The prescription drug benefit was nothing but a bonanza for the pharmaceutical industry. I would change that. I would also adjust the fee schedule, which preferentially rewards highly paid specialists for very expensive tests and procedures. For the system to work, it would have to be a nonprofit delivery system.
Q. How much could we save in administrative costs?
A. On average, the private insurance industry takes 15 to 20 percent right off the top of the premium dollar for its administrative costs and profits. That’s a lot to siphon off by an industry that adds almost nothing of value. It’s just a middleman. Medicare has overhead costs of less than 3 percent.
With the money in the system right now, we could cover everyone for every medically necessary service. But the system has to be distributed according to medical need and not as it currently is — as a commodity. Today, those who can pay get lots of M.R.I.’s they don’t need, while those who are uninsured can go without ones they do need.
Q. Military historians say we’re always fighting the last war. Is Mr. Obama now fighting the last health care war, in which Congress rejected the Clinton plan partly because it was developed without consulting other interested parties?
A. Yes. Mr. Obama has decided that he will listen to everybody. But it’s not working for him, because the public can’t become enthusiastic about a plan that doesn’t exist. That’s what he’s asking. Now Congress has gone home, and for the next month the special interests will be out there scaring people with stories of rationing and socialized medicine.
Q. Is the president really bringing everyone to the table?
A. He’s bringing everyone to the table except the single-payer people. It’s very odd. When he was a state senator, he emphatically favored a single-payer system. And in his July 22 press conference on health care, he stated that the only way to provide universal health care is with a single-payer system. Then he moved right on, as if that was somehow self-evidently absurd.
Q. So are you opposing this reform?
A. I am, though not for the same reasons as the Republicans and Blue Dogs. I’m opposing it more in sorrow than in anger. I’m afraid the president squandered a good opportunity.
By Anne Underwood
August 12, 2009
September 16, 2009
Questions for Dr. Marcia Angell
Health Care in Other Countries: Questions for T. R. Reid
New York Times "Prescriptions":
T. R. Reid was a bureau chief in Tokyo and London for The Washington Post. His new book, “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care,” is a systematic study of the health systems in seven countries that was inspired in part by his family’s experiences living overseas and receiving health care abroad. Mr. Reid also produced a 2008 documentary on the same topic for PBS called “Sick Around the World.” He spoke with blog contributor Anne Underwood.
Q. We’ve just passed the eighth anniversary of 9/11. You make a shocking comparison in your book between that crisis and the state of American health care.
A. On Sept. 11, 2001, roughly 3,000 Americans were killed by terrorists. Since then, we’ve spent hundreds of billions of dollars to make sure that doesn’t happen again. But the same year — and every year since, according to the National Academies of Science — about 22,000 Americans died of treatable diseases because they couldn’t afford health care. And we let that go on. Do Americans consider that acceptable? To me, it’s not. The American people must not realize how cruel our system is, because if they did, they’d change. We’re not a cruel people.
Q. You focused primarily on Canada, Great Britain, France, Germany, Switzerland, Taiwan and Japan. Why?
A. I chose big, rich, advanced, free-market democracies that might make a good model for the United States. In each of these countries, they set a goal of providing health care for all and found a way to get there. As I argue in the book, health care systems are moral instruments. They reflect a country’s basic moral values.
Q. Americans seem to think that all advanced countries with universal coverage have single-payer systems. Actually, that’s not true.
A. A lot of what Americans think they know about health care overseas is not accurate. Japan has 3,000 payers. Germany has 220 payers. Switzerland has 70. But in many ways, the systems in these countries act like single payers, with one set of rules, one set of forms.
In Japan, there is one price for each procedure for the entire country. They publish a huge book thicker than the Tokyo phone book that lists 30,000 medical procedures and sets the price for each. There’s one set price for a cut requiring six stitches on the back of the hand and another for a cut requiring six stitches on the thigh.
Q. Many Americans are saying that universal coverage is too expensive. But you say it’s essential for controlling medical costs. Why?
A. If everybody’s in the system, you have the political will to make tough decisions about cost control. If you say, “We will cover the $20,000 drug for breast cancer, but not the $40,000 drug,” that means some women may die sooner than they might have. But if the system covers everybody, you know the money saved is going to be used to help a sick child or a mother with a difficult pregnancy. That makes it easier for society to accept those tough decisions.
In the U.S., when Aetna or WellPoint declines to pay for a drug or a procedure, the money saved goes to enhance the insurer’s profit, not to pay for another person’s treatment. So people are less willing to tolerate cost controls. All over the world, health ministers told me that the first step is universal coverage — and that generates the political will to impose controls.
Q. Critics argue that if we institute cost controls, it will stifle innovation in both drug discovery and the development of new technologies.
A. That’s completely false. Overseas, cost controls drive innovation. In Denver, I had an M.R.I. that cost $1,434 dollars. The exact same procedure in Japan today costs about $105. That’s because the government kept reducing the price it would pay for M.R.I.’s. Japanese researchers had to devise ways to get the same scan for less money, and they did, developing much cheaper machines.
As for drugs, it’s also false. Lots of drugs that make TV news in America come originally from labs in the U.K., Switzerland or Japan.
Q. And yet other countries also have trouble keeping costs in line.
A. Modern medicine is extremely expensive. Other countries constantly have to decide which new procedures and medicines they will pay for.
Q. Which sounds like rationing.
A. Other countries definitely ration, but so do we. Here’s the difference. In other developed countries, there is a basic level of care that everybody gets. Our method is to leave tens of millions of people out of the system, which is the harshest way to ration.
Q. Did other countries find it difficult to institute universal coverage?
A. In Switzerland it was very tough, because Switzerland is home to huge drug companies and giant international insurance companies. Until the 1990s, they were making a profit on health insurance. They copied the pre-existing conditions rule of American insurers and tried not to sell policies to anyone who might make a claim. They hired lots of underwriters to deny claims, like our guys do. And by 1994, Switzerland got to point where 5 percent of people couldn’t afford health insurance.
For the Swiss, this was shocking. They had national referendum on universal coverage, and most of the business community opposed it. The giant insurance companies opposed it, and the drug companies opposed it. But the reform passed and took effect on Jan. 1, 1996. The result was that insurers had to cover everybody and they couldn’t make a profit on basic health insurance.
Q. How’s it working out?
A. I went there in 2007, and everyone was happy. The pro-business Christian Democratic Party is proud of it. And the insurance companies are doing better than before the reform. Here’s why. They’re now required to sell basic coverage to anybody for no profit, and there are strict controls on pricing and administrative costs. But the same companies sell supplemental policies on a for-profit basis that cover things like private hospital rooms or Viagra. In addition, the same companies sell life insurance and fire insurance. They use the basic health insurance plan, for which they can’t make profit, as a loss leader for other lines of business. All of them are bigger and making more money than before the change.
Q. The rate of medical bankruptcies in this country is alarmingly high. What about overseas?
A. When I made the documentary “Sick Around the World,” I asked the health minister in every country I examined, “How many people in your country went bankrupt last year due to medical bills?” They looked at me as if I’d just asked how many flying carpets they rode on their way to work. In Canada, it was zero. In the U.K., zero. In Germany, zero. Japan, zero. Taiwan, zero. The other rich countries don’t let it happen. When I asked the president of Switzerland, who belongs to the pro-business Christian Democratic Party, he said, “Nobody. It would be a huge scandal if we let that happen.”
Q. Another issue on the table now is tort reform. Are medical malpractice suits a problem in other countries?
A. No. Every country has come up with a mechanism to compensate patients who are injured by doctors and hospitals. These injuries happen in every country. If doctors are seriously negligent, you need a system to discipline them. But nobody does this through the tort system except the United States because it’s a very expensive way to do it. Most of the money doesn’t get to injured person, but gets paid to court system, investigators, lawyers.
Q. If other countries don’t handle malpractice through the tort system, how do they do it?
A. In Germany . . . it’s like an accreditation body that tests you. In Britain, they have an agency called NICE, the National Institute for Health and Clinical Excellence. NICE issues guidelines for treating medical ailments. In the U.K., if you demonstrate that you followed NICE guidelines, you can’t be held liable. Even if patients are horribly injured and impaired for life, you can’t be disciplined as long as you followed the guidelines.
Q. So other countries have no huge jury awards to drive up costs?
A. You read about massive judgments in this country with injured patients receiving tens of millions of dollars. A major part of that is, once someone is injured or crippled, the damage award includes lifetime care. In the United States, that’s really expensive. But if somebody won a judgment of lifetime medical care in the U.K., the cost would be zero. Health care is free. And if you won a big tort judgment in France or Belgium, an award of lifetime care would be vastly cheaper than in America.
Q. Do you support any of the plans being discussed on Capitol Hill?
A. I think all the plans that we’ve seen in America are tinkering at the margins of a system that is unfair and grossly expensive. On the other hand, I came away from writing the book feeling optimistic, because I know we could get to universal coverage at reasonable cost if we want to. All the other developed countries in the world have done it. Are you telling me Taiwan can do this and the U.S.A. can’t? Come on.
Q. Do you see a way of getting back on track?
A. It takes a leader. My book focused on people like Tommy Douglas in Canada, Otto von Bismarck in Germany and Nye Bevan in the U.K., who persuaded their countrymen that they needed universal coverage. It will take someone who can grab the moral imperative and remind us that the important issue is not whether insurance companies make 4 percent or 6 percent on their coverage, but whether people get medical care when they need it.
By Anne Underwood
September 15, 2009
September 14, 2009
If You Support Universal Health, You Must be an America Hater
Throughout the three years I lived in Canada, and the eight years I lived in Denmark, I would periodically return to the U.S. to see family and friends. I would regale my American acquaintances with stories of what it was like to live in a land with little to no poverty, absurdly cheap to outright free higher education, a generous minimum wage and free government healthcare. I was surprised and even hurt to find that instead of inspiring my listeners to lobby for such things themselves, I was branded an “America hater.” My hope that we might bring the quality of life indicators in the U.S. up to, or at least approaching, those of every other economically developed nation was viewed not, as I had conceived it myself, as an expression of fervent patriotism, but as outright treachery. How dare I say that anyone anywhere in the world was actually living better than people in the U.S!
Health Care in Other Countries: Japan
New York Times "Prescriptions":
Timothy Stoltzfus Jost is a law professor at Washington and Lee University and frequently writes on comparative health care policy. His work includes an examination of insurance coverage in Switzerland and a comparison of the Swiss and Dutch systems. He spoke to the freelance writer Anne Underwood.
BY THE NUMBERS
Switzerland
- Life expectancy: 82 years (USA: 78)
- Infant mortality: 4 per 1,000 live births (7)
- Health spending as a percentage of GDP: 11.3 (15)
- Percentage of health spending that is private: 40 (54)
- Doctors per 10,000 people: 40 (26)
Q. The Swiss health care system relies on public-private approaches that have been recommended as models for the United States. What are the similarities?
A. In 1996, Switzerland instituted an individual mandate by which people are legally required to purchase health insurance in a competitive market. People buy coverage from private insurers, and the government provides subsidies for those who can’t afford coverage. About a third of the population receives subsidies.
Q. Is there an employer mandate, too?
A. No, it’s an individual mandate. Group health insurance does not exist in Switzerland.
Q. That’s a major difference between the Swiss system and most of the proposals in Congress. Are there others?
A. The most important difference is that health insurance in Switzerland is provided by nonprofit insurers — though some are affiliated with for-profit companies that offer supplemental policies along the lines of Medigap in the United States. The basic benefit package is defined by law and is quite generous. Maximum drug prices are regulated.
Q. Do many people buy supplemental insurance?
A. About a third of the population purchases voluntary supplemental insurance that covers things like private hospital rooms and dental benefits.
Q. Do the Swiss have a choice among policies and insurance companies?
A. They do. The policies differ mainly on deductibles. The standard annual deductible is 300 Swiss francs, or about $200 for adults. There is no deductible for children under 18. Individuals can reduce their premiums by electing plans with higher deductibles — up to 2,500 Swiss francs, or about $2,000. Once the deductible has been met, you pay coinsurance of 10 percent of covered expenses, up to a maximum of 700 Swiss francs. For brand-name prescription drugs, you pay 20 percent of the price if there’s a generic equivalent.
There are also some managed care plans, in which about 12 percent of the people are enrolled.
Q. In the United States, it can be quite confusing trying to purchase an insurance policy on your own. How do the Swiss navigate the system? Is there a national insurance exchange like the one that’s being proposed here — a sort of marketplace where it’s easy for people to go and compare policies?
A. There is no insurance exchange, but Internet comparison sites are available and forms are standardized to minimize switching costs. Most people, however, stay with their insurer and seldom switch.
Q. Are the policies expensive?
A. Yes. In 2004, 40 percent of households — or one third of individuals — received subsidies.
Q. Is there a public option in Switzerland?
A. There is no government-run plan to compete with the private nonprofit plans. But health insurance is considered social insurance. It’s not a for-profit enterprise.
Q. Can the Swiss go to any doctor they want?
A. For the most part, although there are some managed care plans with networks. Otherwise, the Swiss have a free choice of physicians and specialists. There is no “gatekeeper” system limiting their access to specialists.
Q. What does the Swiss health system do particularly well?
A. They’ve achieved near universal coverage. But even before the reform, 96 percent of the population was covered. They’re a very risk-averse society. The culture is that you just don’t go uninsured. Now, with reform, they’re close to 99 percent. But the country is still struggling with how to handle individuals who fail to comply with the mandate — mainly the poor and recent immigrants.
Q. How is the quality of care?
A. The quality of care is excellent. Waiting times are not reported to be a serious problem in Switzerland, and most people can get the services they need quite expeditiously. Modern, high-technology services are readily available. Coverage of some new drugs and procedures, however, is reviewed for effectiveness, and some drugs and procedures available in other countries may not be available in Switzerland if they are not considered to be cost-effective.
Q. What is your biggest criticism of the Swiss system?
A. It hasn’t done well at controlling costs. Switzerland is second only to the United States in the percent of GDP spent on health care. It’s also second to the United States in the rate of health care inflation. Probably the most important reason is that Switzerland is a wealthy nation, and wealthy nations spend more on medical care. But a particular problem is that the Swiss use more health care resources than even we do in the United States, with more doctors, hospitalizations and certain high-tech procedures.
Q. So competition among companies doesn’t keep prices down?
A. In theory, insurers compete with each other to bring down prices. In fact, it doesn’t work all that well. There is also enough wiggle room in the system that insurers are able to cherry-pick — to attract enrollees who are good risks and get rid of those at higher risk. As long as insurers have control over the plan design and some control over the premium classifications, they can manipulate the risk pool. For example, if they give good service to the healthy and less adequate service to the less healthy, the less healthy may try to move on to another insurer.
Q. What is the most important lesson Americans should learn from the Swiss system?
A. You can achieve universal coverage through an individual mandate, coupled with subsidies for people who can’t afford health insurance. But it’s not going to get you cost control unless you enact further measures.
By Anne Underwood
September 18, 2009
Health Care in Other Countries: Canada
New York Times "Prescriptions":
Theodore R. Marmor is professor emeritus of public policy and political science at Yale University and a former fellow of the Canadian Institute for Advanced Research. He is the author of “The Politics of Medicare” (Aldine Transaction, 2000). He spoke to freelance writer Sarah Arnquist.
BY THE NUMBERS
Canada
- Life expectancy: 81 years (USA: 78)
- Infant mortality: 5 per 1,000 live births (7)
- Health spending as a percentage of GDP: 10 (15)
- Percentage of health spending that is private: 30 (54)
- Doctors per 10,000 people: 19 (26)
Q. How does the Canadian system provide health care at lower cost than the American system?
A. Canada’s national health insurance, called Medicare, provides hospital and physician insurance to all Canadian citizens. It does not provide health care directly from government hospitals or through publicly employed physicians. Imagine 10 provincial nonprofit health insurance plans without deductibles, co-insurance or co-payments for medically prescribed treatment.
Canada pays for more hospital days and doctor visits per capita than the United States but spends about 40 percent less. Canadians pay their doctors, nurses and other medical personnel less, and provide fewer very expensive equipment and services. Open heart surgery, for example, would cost about 30 percent less in Toronto than in Chicago. The lower supply of expensive equipment means Canadians wait somewhat longer for those services, but in recent years improved management has reduced waiting lists for services like M.R.I. scans. Canada has more general practice doctors per capita than the United States does, so basic office visits are considerably less costly. Private spending, which is about 30 percent of all Canadian health spending, has increased more rapidly than public expenditures over the past 40 years.
The final reason Canada has lower costs is that the provincial governments are responsible for financing health care and directly face the pressure of rising health costs. They must act to control the costs because other government services compete for public funding.
Q. What does the Canadian health system do particularly well?
A. Two features stand out. One is that the financing of medical care is extraordinarily simple for patients, physicians and hospitals. Patients face no bills for acute services and no co-payments. Doctors are paid electronically each month according to a set payment rate, and the hospitals must follow a set budget. Bankruptcy from medical bills, insurance disputes and billing confusion do not exist as problems.
The second strength is clarity about the purposes public health insurance serves and for many Canadians a sense of pride that access to medical care is not treated as a market transaction. Medical care is allocated more by ability to benefit than by ability to pay, however, disparities in medical use still exist between people of different classes and educational backgrounds.
Q. What is your biggest criticism of it?
A. The continued nastiness of federal-provincial negotiations about the shared financing of Medicare is one unappealing feature of the Canadian system. This dual responsibility leads to endless blaming between the national and provincial governments for the pressures of medical expenditures on the budgets of other public programs and tax levels. This, in turn, has partly prevented Canada from handling drug costs in the uncomplicated Medicare program.
Q. What is the most important lesson Americans should learn from the Canadian system?
A. Until the 1960s, Canada was very similar to the United States in its medical, hospital, economic and social context. Canada’s experience since then demonstrates that it is possible to have public health insurance that largely fulfills the explicit purposes set out in the Canada Health Act of 1984: universal insurance, comprehensive hospital and physician benefits (without hidden insurance policy constraints), portable coverage across the nation, clear accountability through the political process and no significant financial barriers to care.
By Sarah Arnquist
August 14, 2009
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)
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
--Ironic Times