The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

Dr. Bertrand Tamalet is an orthopedist who knows what kind of surgery Reid received 30 years earlier. That surgery, which used a screw to hold a joint in place, was invented by the French orthopedic surgeon Dr. Maurice Latarjet. However, in the US, the surgery is identified as the Bristow procedure, after the surgeon and orthopedist who popularized it there. It was also a French orthopedist, Dr. Jules Émile Péan, “who implanted the world’s first man-made joint” in March 1892 (47). To save the shoulder of a patient with “a severe infection due to tuberculosis” who also refused amputation, Péan came up with the idea of installing an artificial joint instead. The surgery was a success. Later, the artificial shoulder was donated to the Smithsonian and is now on display at the National Museum of Health and Medicine in Washington, D.C.

It was Dr. Tamalet who related this story to Reid. He then charged Reid $33.80 for the consultation—a predetermined fee that insurance would reimburse at around 70%. Not everyone pays the predetermined fee in full. The poor and those on welfare are billed about a quarter of the regular cost of treatment. The poorest patients and those suffering from chronic illnesses pay nothing. In these cases, the doctor gets paid through the French social security system. Also, pregnant women do not pay medical fees during the last five months of pregnancy and the first four months after childbirth. No patient is ever required to pay more than $100 within a single day, no matter the cost of the prescribed treatment.

Dr. Tamalet’s office is modest, like many in France. Most noticeably, there are no file cabinets and shelves filled with patients’ records. There is no need due to the carte vitale, which contains all of a patient’s health records and billing information. Every French doctor’s office and hospital accepts this card and usually has a sign reminding patients of this national standard.

The French system both encourages good health standards and treatment for those who get sick. It also does the best out of all countries in treating curable diseases. Finally, the French health insurance system covers every French resident and “guarantees everyone a roughly equal level of treatment” (49). There are also more hospital beds and more doctors per capita compared to the US. While Americans visit the doctor about five times per year, the French go about eight times per year. They also take more medication and get more shots.

The French health care system falls within the Bismarck model—that is, private doctors treat patients who buy insurance, both from a government plan and private insurers, to cover the cost of treatments. As in the U.S, the French get their health insurance through the employer, with both the employer and employee splitting the cost of premiums. The employee’s cost deduction is withheld from a paycheck. There are specific charges for each treatment and procedure and any copay is due at the time of the visit. There are both public and private hospitals, as in the US. However, in France, most private hospitals have a care specialty. Most French workers cannot choose their health insurance plans. They get the plan that is associated with their line of work or where they live, and they must keep that plan for the rest of their lives. Unlike some countries with a national health care system, no one waits to see a general practitioner or specialist in France—unless they need to see a pediatrician. There are few of the latter in France. However, postnatal nurses visit both mother and child for free in the first few weeks after birth.

The insurance plans are nonprofit “sickness insurance funds” that exist solely to pay for care, not to provide dividends to investors (50). No French insurer can turn down a patient for coverage, and insurance doesn’t end simply because one loses or quits a job. When someone is unemployed, the government pays the former employer’s half of the premium. Finally, insurers must always pay for a claim after a doctor submits it, and it is illegal to delay reimbursement.

Administrative costs are also low in France—less than 5%. In contrast, in the US, health insurance companies spend about 20% of their income from premiums on administrative expenses. Additionally, ambulances are free, and no one needs a referral from a general physician before seeing a specialist. This practice of referrals, known as the “gatekeeper” system, is also common in the US. The French attempted to implement it in 1997 to save money, but a protest led by doctors and patients ensued.

France spends around $3,165 per capita yearly on health insurance that covers every citizen, while the US spends over $7,000 on health care that leaves tens of millions of American citizens without insurance coverage. France’s spending is less than 10% of its gross domestic product (GDP), while, in the US, the spending is at 17%. If the US spent what the French do on health care, the country would save $600 billion each year. That additional revenue would provide the necessary funds to cover every American. On the other hand, the French may not have the most cost-efficient health care. Great Britain, Sweden, Italy, Spain, and the Netherlands all spend less than France on health care. This awareness, has led the French to look for ways to cut costs.

The French health insurance system began in 1928 and initially only covered working class people in particular fields of industry. It wasn’t until 2000 that every single French citizen received coverage. Now, everyone must belong to the national health insurance fund and both employed and retired people belong. Premiums are either withheld from paychecks or pensions checks. The three primary insurance funds are for salaried workers, farm-workers, and the last for both professions and independent contractors. The premiums are very cheap. As of 2007, if someone made $20,000 per year, he or she would have paid $12.25 per month. The employer, on the other hand, paid $208.

It is also possible to purchase supplemental health insurance in France from either a nonprofit cooperative or a for-profit insurance company, which is cheaper. These forms of insurance are used to pay for things such as cosmetic surgery. The French government negotiates prices with doctors, hospitals, and drug companies. Doctors belong to a labor union that negotiates on their behalf, and the negotiations are transparent.

As simple and straightforward as this system may see, the French continually reform their health care system. There have been reforms in 1996, 1997, 2000, and 2004. Sometimes the changes are due to public concern over the quality of care, but most of the concerns are about money. Many French people believe that the health care system is too expensive to maintain long-term. The sickness funds have operating deficits each year. In 2004, there was yet another attempt to install the gatekeeper system to save on costs. After the 2004 law, if a patient went to a specialist without a general physician’s referral, they would have paid a 60% copay instead of 70%—about $4.50 extra.

Some doctors also complain that the French health care system is both too pricy and too cheap when paying doctors. Prices and treatment are set by the Health Ministry. A doctor who works around 60 hours per week makes about $52,000 per year. However, there are perks. Doctors take the standard five weeks of vacation per year, common to French citizens, and can bill their cars to their medical office. French specialists, such as Dr. Tamalet, make around $65,000 per year working in a public hospital. They can make additional income by maintaining a private practice. In total, Dr. Tamalet brings in $130,000 per year—far less than American orthopedists. Then again, French physicians pay relatively little for malpractice insurance. A general physician will pay around $130 yearly, while specialists like Dr. Tamalet pay $650. More importantly, no French doctor ever thinks that he or she will be sued.

The lack of pressure imposed by income and malpractice suits allows French doctors to give the best medical advice they can. This also includes referring patients to specialists for additional care. It was the physician Dr. François Bonnaud who referred Reid to Dr. Tamalet. Tamalet asked Reid about his shoulder problem, then manipulated the shoulder and arm to assess the damage. He concluded that the best thing for Reid to do would be to start an intense physical therapy regime. The therapy would not eliminate the pain, but it would reduce it. Reid told Dr. Tamalet that American doctors had prescribed a total shoulder arthroplasty. Tamalet said that Reid could do that, though he wouldn’t benefit so much from it, due to the nature of his injury. Furthermore, Reid wasn’t suffering from constant pain. Patients who opted for arthroplasty constantly suffered from pain. Tamalet told Reid that, if he opted for arthroplasty, the sickness funds would cover the costs of both surgery and his hospital stay, which would come to about $10,000. Reid, however, would have to wait about a month to get surgery.

The French insurance system is built around the idea of solidarity—that is, that all citizens must help each other during difficult moments. This idea that there should be a national system providing everyone with health care is a European invention, created during the 19th century in Germany.