Alan Stolier, MD/




By now it is no secret that France ranks near the top, and considerably higher than the United States, on various health measures such as adjusted life expectancy, infant mortality and life expectancy among adults. The World Health Organization concluded that France has the world’s number 1 healthcare system. Interestingly, France has more doctors per capita than the US and more hospital beds. The French are not shy about visiting the doctor, making about 8 visits per year compared to 5 in the US. Moreover, they take more pills and receive more injections than Americans do. In a nutshell, the French appear to get high-quality health care while paying less than we do.



The healthcare system in France is a variation of the Bismarck Model. It is a system of private doctors who treat patients who buy health insurance from a government health plan or from private insurers. As here, mostly private doctors charge patients on a fee-for-service basis. Health insurance is obtained through the job with costs being split between employer and employee. Premiums are withheld from the worker’s paycheck. Moreover, as in the US, there are co-pays, though in France most are reimbursed by the insurance plan.

Most importantly, health insurance funds in France (caisses d’assurance maladie or sickness funds) are nonprofit! “Their main concern is not providing a return to investors but, rather, paying for people’s health care.” As in the U.S. since the Affordable Care Act, you cannot be turned down for preexisting conditions. In France however, insurance companies cannot terminate you if you lose your job. In fact, if you do lose your job you continue with the same plan, and the government will pay the employers share of the premium. In France, there are no deductibles and it is illegal for insurance companies to delay payment (doctors are usually paid within a week). Administrative expenses, which in US private insurance companies runs about 20%, is less than 5% in France. (Interestingly, administrative costs for Medicare in the US is less than 3%!) The low cost is understandable given that the French insurance companies don’t spend money on marketing, viewing and denying claims or paying dividends to stockholders.

Aside from pediatricians which are in short supply, waiting times are about the same as in the U.S. The French can go to any doctor in the country, including specialists. There is no gatekeeper system. Interestingly, in 1997, the government did try to establish a gatekeeper system. The rebellion was furious. Demonstrations by patients and doctors blocked the streets of Paris and eventually, the government caved.

In France, “everybody must belong to a health insurance fund: it’s illegal to opt out, no matter how healthy you think you are.” There are 3 main funds. One for salaried workers, one for farm-workers and one for professionals and self-employed. There are also supplemental policies which can be purchased from nonprofit or for-profit companies. Because these policies are extremely cheap, approximately 90% of workers buy it.

One of the most important aspects of the French system is the Carte Vitale. It was initially introduced in 1998. It is a green plastic credit card and is “the central administrative tool of French medicine.”  All medical facilities including doctors’ offices have a reader for the card. The card contains all the patient’s insurance details. All citizens, 16 and older are required to have one. The card allows direct reimbursement from the insurance fund without requiring additional forms. In 2008, Carte Vitale 2 was introduced. This new card equipped with a memory chip will allow the existence of electronic health records. Essentially, the French will carry their EMR with them from doctor to doctor, from lab to lab and hospital to hospital. The card currently allows direct reimbursement from the insurance fund without sending additional forms.

On the downside, French doctors make approximately a third of what their counterparts make in the United States. However, no French doctor pays a penny to go to college or medical school; so that none graduate with the kind of debt facing American doctors (~$100,000). Moreover, malpractice insurance is a fraction of what’s paid in the U.S. And, most French doctors never expect to be sued. Also, most healthcare funds are acting at a deficit as the system costs are increasing faster than the economy as a whole.

So, France is a multipayer healthcare system with multiple sickness funds and several supplemental plans. In practice though, France acts like a single-payer system because the National Health Ministry essentially dictates what providers can charge for most treatments and what prices are paid for prescriptions. Unlike the US, the French government negotiates prices on behalf of sickness funds, with doctors, hospitals, and pharmaceutical companies. The French are informed up front, in many instances with a visible waiting room sign, how much they will pay for each treatment or procedure and how much they will get reimbursed by insurance. According to the World Bank, in 2014 France spent approximately $4959 per capita compared to $9403 for the U.S. Ultimately, the French system is one that uses private doctors, hospitals, and insurance companies. Costs are controlled by strict and uniform price control (including doctor fees) as well as nonprofit insurance plans.


Link to Part 1: http://www.breastcarenetwork.com/news/healthcare-systems-around-the-world

Link to Part 2: http://www.breastcarenetwork.com/news/healthcare-systems-around-the-world-2

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