31 by liaoxiuli5


									                                                   INTERNATIONAL PERSPECTIVES FORUM 

The Health Care System Under French National Health
Insurance: Lessons for Health Reform in the United States
     The French health system             | Victor G. Rodwin, PhD, MPH
  combines universal coverage
  with a public–private mix of
  hospital and ambulatory care            THE FRENCH HEALTH CARE               out reforming the overall man-         levels of resources (Table 2), and
  and a higher volume of service
                                          system has achieved sudden no-       agement and organization of the        a higher volume of service provi-
  provision than in the United
                                          toriety since it was ranked No. 1    health system. This strategy has       sion (Table 3) than in the United
  States. Although the system
                                          by the World Health Organiza-        exacerbated tensions among the         States.32 There is wide access to
  is far from perfect, its indica-
  tors of health status and con-          tion in 2000.1 Although the          state, the NHI system, and             comprehensive health services
  sumer satisfaction are high;            methodology used by this assess-     health care professionals (princi-     for a population that is, on aver-
  its expenditures, as a share of         ment has been criticized in the      pally physicians), tensions that       age, older than that of the United
  gross domestic product, are             Journal and elsewhere,2–5 indi-      have long characterized the po-        States, and yet France’s health
  far lower than in the United            cators of overall satisfaction and   litical evolution of French            expenditures in 2000 were
  States; and patients have an            health status support the view       NHI.13–15                              equal to 9.5% of its gross domes-
  extraordinary degree of choice          that France’s health care system,        Although the French ideal is       tic product (GDP) compared with
  among providers.                        while not the best according to      now subject to more critical scru-     13.0% of GDP in the United
     Lessons for the United
                                          these criteria, is impressive and    tiny by politicians, the system        States.17
  States include the importance
                                          deserves attention by anyone in-     functions well and remains an             The health system in France is
  of government’s role in pro-
                                          terested in rekindling health        important model for the United         dominated by solo-based, fee-for-
  viding a statutory framework
  for universal health insurance;         care reform in the United States     States. After more than a half         service private practice for ambu-
  recognition that piecemeal re-          (Table 1). French politicians        century of struggle, in January        latory care and public hospitals
  form can broaden a partial pro-         have defended their health sys-      2000, France covered the re-           for acute institutional care,
  gram (like Medicare) to cover,          tem as an ideal synthesis of soli-   maining 1% of its population           among which patients are free to
  eventually, the entire popula-          darity and liberalism (a term un-    that was uninsured and offered         navigate and be reimbursed
  tion; and understanding that            derstood in much of Europe to        supplementary coverage to 8%           under NHI. All residents are au-
  universal coverage can be               mean market-based economic           of its population below an in-         tomatically enrolled with an in-
  achieved without excluding pri-         systems), lying between Britain’s    come ceiling.16 This extension of      surance fund based on their oc-
  vate insurers from the sup-
                                          “nationalized” health service,       health insurance makes France          cupational status. In addition,
  plementary insurance market.
                                          where there is too much ra-          an interesting case of how to en-      90% of the population sub-
  (Am J Public Health. 2003;93:
                                          tioning, and the United States’      sure universal coverage through        scribes to supplementary health
                                          “competitive” system, where too      incremental reform while main-         insurance to cover other benefits
                                          many people have no health in-       taining a sustainable system that      not covered under NHI.33 An-
                                          surance. This view, however, is      limits perceptions of health care      other distinguishing feature of
                                          tempered by more sober ana-          rationing and restrictions on pa-      the French health system is its
                                          lysts who argue that excessive       tient choice. Following an over-       proprietary hospital sector, the
                                          centralization of decisionmaking     view of the system, and an as-         largest in Europe, which is acces-
                                          and chronic deficits incurred by     sessment of its achievements,          sible to all insured patients. Fi-
                                          French national health insurance     problems, and reform, this article     nally, there are no gatekeepers
                                          (NHI) require significant            explores lessons for the United        regulating access to specialists
                                          reform.9,10                          States of the French experience        and hospitals.
                                             Over the past 3 decades, suc-     with NHI.                                 French NHI evolved from a
                                          cessive governments have tin-                                               19th-century tradition of mutual
                                          kered with health care reform;       THE FRENCH HEALTH                      aid societies to a post–World
                                          the most comprehensive plan          CARE SYSTEM                            War II system of local demo-
                                          was Prime Minister Juppé’s in                                               cratic management by “social
                                          1996.11,12 Since then, whether          The French health care system       partners”—trade unions and
                                          governments were on the politi-      combines universal coverage            employer representatives—but it
                                          cal left or right, they have pur-    with a public–private mix of hos-      is increasingly controlled by the
                                          sued cost control policies with-     pital and ambulatory care, higher      French state.34 Although NHI

January 2003, Vol 93, No. 1 | American Journal of Public Health                              Rodwin | Peer Reviewed | International Perspectives Forum | 31
                                                                    INTERNATIONAL PERSPECTIVES FORUM 

    TABLE 1—Health Status and Consumer Satisfaction Measures: France, United States, Germany,
    United Kingdom, Japan, and Italy

                                                                                             France                    US                 Germany            UK               Japan          Italy

    Health status
       Infant mortality (deaths/1000 live births), 1999a                                       4.3                     7.2b                   4.6             5.8               3.4           5.1
       LEB (female), 1998a                                                                    82.2                    79.4                   80.5            79.7              84.0          81.6c
       LEB (male), 1998a                                                                      74.6                    73.9                   74.5            74.8              77.2          75.3c
       LE at 65 (female), 1997a                                                               20.8                    19.2                   18.9            18.5              21.8          20.2
       LE at 65 (male), 1997a                                                                 16.3                    15.9                   15.2            15.0              17.0          15.8
       Severe disability-free life expectancy (female), 1990/1991d                            14.8                    NA                     NA              13.6              14.9          NA
       Severe disability-free life expectancy (male), 1990/1991d                              18.1                    NA                     NA              16.9              17.3          NA
       Potential years of life lost per 100 000 population (female), 1993e                  2262                    3222                   2713            2642              1914          2136
       Potential years of life lost per 100 000 population (male), 1993e                    5832                    6522                   5752            4688              4003          4873
    Consumer satisfaction, %
       Only minor changes needed, 1990f                                                        41                     10                         41          27                29            12
       Very satisfied, 1996g                                                                   10                     NA                         12.8         7.6              NA             0.08
       Fairly satisfied, 1996g                                                                 55.1                   NA                         53.2        40.5              NA            15.5

    Note. US = United States; UK = United Kingdom; LEB = life expectancy at birth; LE = life expectancy; NA = not available.
      Source. Organization for Economic Cooperation and Development.6(p27)
      Defined as life expectancy with the ability “to perform those activities essential for everyday life without significant help.”6(p27,31)
      Source. Organization for Economic Cooperation and Development.6(p30)
     Source. Harvard–Louis Harris Interactive 1990 Ten-Nation Survey, cited by Blendon et al.7
      Source. Eurobarometer Survey, 1996, cited in Mossialos.8

consists of different plans for dif-                   Unlike Medicare, however,                                 of coverage. Following its original                lowing an agrarian metaphor—as
ferent occupational groups, they                       French NHI coverage increases                             passage in 1928, the NHI pro-                      a set of 3 sprouting branches:
all operate within a common                            as individual costs rise, there are                       gram covered salaried workers in                   (1) pensions, (2) family allow-
statutory framework.35–37 Health                       no deductibles, and pharmaceu-                            industry and commerce whose                        ances, and (3) health insurance
insurance is compulsory; no one                        tical benefits are extensive. In                          wages were under a low ceil-                       and workplace accident cov-
may opt out. Health insurance                          contrast to Medicaid, French                              ing.38,39 In 1945, NHI was ex-                     erage.20 The first 2 are managed
funds are not permitted to com-                        NHI carries no stigma and pro-                            tended to all industrial and com-                  by a single national fund, while
pete by lowering health insur-                         vides better access. In summary,                          mercial workers and their                          the third is run by 3 main NHI
ance premiums or attempting to                         French NHI is more generous                               families, irrespective of wage lev-                funds: those for salaried workers
micromanage health care. For                           than what a “Medicare for all”                            els. The extension of coverage                     (Caisse Nationale d’Assurance
ambulatory care, all health in-                        system would be like in the                               took the rest of the century to                    Maladie des Travailleurs Salariés,
surance plans operate on the                           United States, and it shares a                            complete. In 1961, farmers and                     or CNAMTS), for farmers and
traditional indemnity model—                           range of characteristics with                             agricultural workers were cov-                     agricultural workers (Mutualité
reimbursement for services ren-                        which Americans are well ac-                              ered; in 1966, independent pro-                    Sociale Agricole, or MSA), and
dered. For inpatient hospital ser-                     quainted—fee-for-service prac-                            fessionals were brought into the                   for the independent professions
vices, there are budgetary allo-                       tice, a public–private mix in the                         system; in 1974, another law                       (Caisse Nationale d’Assurance
cations as well as per diem                            financing and organization of                             proclaimed that NHI should be                      Maladie des Professions Indépen-
reimbursements. The French in-                         health care services, cost shar-                          universal. Not until January                       dentes, or CANAM). In addition,
demnity model allows for direct                        ing, and supplementary private                            2000 was comprehensive first-                      there are 11 smaller funds for
payment by patients to physi-                          insurance.                                                dollar health insurance coverage                   workers in specific occupations
cians, coinsurance, and balance                                                                                  granted to the remaining unin-                     and their dependents, all of
billing by roughly one third of                        NATIONAL HEALTH                                           sured population on the basis of                   whom defend their “rightfully
physicians.                                            INSURANCE                                                 residence in France.40                             earned” entitlements.41
   Like Medicare in the United                                                                                      NHI forms an integral part of                      The CNAMTS covers 84% of
States, French NHI provides a                            NHI evolved, in stages, in re-                          France’s social security system,                   legal residents in France, which
great degree of patient choice.                        sponse to demands for extension                           which is typically depicted—fol-                   includes salaried workers, those

32 | International Perspectives Forum | Peer Reviewed | Rodwin                                                                          American Journal of Public Health | January 2003, Vol 93, No. 1
                                                                INTERNATIONAL PERSPECTIVES FORUM 

    TABLE 2—Health Care Resources: France and United States, 1997–2000                                                                               to cost sharing and selected ele-
                                                                                                                                                     ments of la médecine libérale
                                Resources                                                          France                               US           (private practice): selection of
    Active physicians per 1000 population                                                        3.3a (1998)                      2.8a (1999)        the physician by the patient,
    Active physicians in private, office-based practice per 1000 population                      1.9b (2002)                      1.7c (1999)        freedom for physicians to prac-
       General/family practice, %                                                               53.3b (2002)                     22.5c (1999)        tice wherever they choose, clin-
       Obstetricians, pediatricians, and internists, %                                           7.5b (2002)                     35.6c (1999)        ical freedom for the doctor, and
       Other specialists, %                                                                     39.2b (2002)                     41.0c (1999)        professional confidentiality. It is
    Nonphysician personnel per acute hospital bedd                                               1.9 (2001)e                      5.7 (2000/01)f     wrongly invoked, however, in
    Total inpatient hospital beds per 1000 populationg (1998)                                    8.5a                             3.7a               the case of fee-for-service pay-
    Short-stay hospital beds per 1000 population                                                 4.0h (2000)                      3.0i (1998)        ment with reimbursement
       Share of public beds, %                                                                  64.2h (2000)                     19.2i (1999)        under universal NHI, for such a
       Share of private beds, %                                                                 35.8h (2000)                     80.8i (1999)        system is more aptly character-
           Proprietary beds as percentage of private beds (1999), %                             56j                              12i                 ized as a bilateral monopoly
           Nonprofit beds as percentage of private beds (1999), %                               44j                              88i                 whereby physician associations
        Share of proprietary beds, %                                                            27k (1998)                       10.7i (1999)        accept the monopsony power of
                                                                                                                                                     the NHI system in return for
      Source. Organization for Economic Cooperation and Development.17                                                                               the state’s sanctioning of their
      Source. CNAMTS.18
      Source. National Center for Health Statistics.19 (These figures exclude federally employed physicians as well as all anesthesiologists,        monopoly power. In the hospi-
    pathologists, and radiologists.)                                                                                                                 tal sector, liberalism provides
      Nonphysician personnel include all hospital employees—administrative, technical, and clinical—excluding physicians. Among the category of      the rationale for the coexis-
    physicians in the United States, we included chiropractors and podiatrists.
      Source. CREDES.20                                                                                                                              tence of public and proprietary
      Source. Acute care beds: American Hospital Association21; nonphysician personnel: Bureau of Labor Statistics.22                                hospitals, the latter accounting
      These differences reflect the use of long-term care beds in French hospitals—public and private nonprofit—as nursing homes.                    for 27% of acute beds in
      Source. DRESS.23
     Source. American Hospital Association.21                                                                                                        France in contrast to 10.7% in
     Source: DRESS.24                                                                                                                                the United States (Table 2).
      Source. DRESS.25                                                                                                                               Also, unit service chiefs in pub-
                                                                                                                                                     lic hospitals have the right to
                                                                                                                                                     use a small portion of their
who were recently brought into                      for fraud and abuse, and pro-                       ding to their occupational cate-             beds for private patients.
the system because they were                        vide a range of customer ser-                       gories. In France, the commit-                  The French tolerance for or-
uninsured, and the beneficiaries                    vices for their beneficiaries.                      ment to universal coverage is ac-            ganizational diversity—whether
of 7 of the smaller funds that                          French NHI covers services                      cepted by the principal political            it be complementary, competi-
are administered by the                             ranging from hospital care, out-                    parties and justified on grounds             tive, or both—is typically justi-
CNAMTS.33 The CANAM                                 patient services, prescription                      of solidarity—the notion that                fied on grounds of pluralism. Al-
and MSA cover, respectively,                        drugs (including homeopathic                        there should be mutual aid and               though ambulatory care is
7% and 5% of the population,                        products), thermal cures in spas,                   cooperation between the sick                 dominated by office-based solo
with 4% covered by the remain-                      nursing home care, cash bene-                       and the well, the active and the             practice, there are also private
ing 4 funds.                                        fits, and to a lesser extent, den-                  inactive, and that health insur-             group practices, health centers,
   All NHI funds are legally pri-                   tal and vision care. Among the                      ance should be financed on the               occupational health services in
vate organizations responsible                      different NHI funds, there re-                      basis of ability to pay, not actu-           large enterprises, and a strong
for the provision of a public ser-                  main small differences in                           arial risk.42                                public sector program for mater-
vice. In practice, they are quasi-                  coverage.                                                                                        nal and child health care. Like-
public organizations supervised                         Smaller funds with older,                       ORGANIZATION                                 wise, although hospital care is
by the government ministry that                     higher-risk populations (e.g.,                      OF HEALTH CARE                               dominated by public hospitals,
oversees French social security.                    farmers, agricultural workers,                                                                   including teaching institutions
The main NHI funds have a net-                      and miners) are subsidized by                          The organization of health                with a quasi-monopoly on med-
work of local and regional funds                    the CNAMTS, as well as by the                       care in France is typically pre-             ical education and research,
that function somewhat like fis-                    state, on grounds of what is                        sented as being rooted in prin-              there are, nevertheless, opportu-
cal intermediaries in the man-                      termed “demographic compensa-                       ciples of liberalism and plural-             nities for physicians in private
agement of Medicare. They cut                       tion.” Retirees and the unem-                       ism.32,42 Liberalism is correctly            practice who wish to have part-
reimbursement checks for                            ployed are automatically                            invoked as underpinning the                  time hospital staff privileges in
health care providers, look out                     covered by the funds correspon-                     medical profession’s attachment              public hospitals.

January 2003, Vol 93, No. 1 | American Journal of Public Health                                                             Rodwin | Peer Reviewed | International Perspectives Forum | 33
                                                                 INTERNATIONAL PERSPECTIVES FORUM 

    TABLE 3—Use of Health Services: France and United States, 1997–2000                                                                                    [3.3%], a specific tax on the
                                                                                                                                                           pharmaceutical industry [0.8%],
                                    Use                                                              France                                   US           and subsidies from the state
    Physician office visits per capitaa (1999)                                                      6.0b                                   2.8c            [4.9%].) The general social con-
    Specialist visits per capita (1999)                                                             1.9b                                   1.4c            tribution, a supplementary in-
    Hospital days per capita (1999)                                                                 2.4d                                   0.9d            come tax (5.5% of wages and all
    Short-stay hospital days per capita (1999)                                                      1.1d                                   0.7d            other earnings) raised specifi-
    Admission rate for short-stay hospital services per 1000 population                           170.1e (2000)                          118.0f (1998)     cally for NHI, was introduced in
    Average length of stay for all inpatient hospital services (1999)                              10.6b                                   7.0g            1991 to make health care fi-
    Average length of stay in short-stay beds (1999)                                                6.2e                                   5.9f            nancing more progressive and to
    Per capita spending on pharmaceuticals, PPP, $ (1999)                                         484h                                   478h              increase NHI revenues by en-
    MRIs per million population                                                                     2.5i (1997)                            7.6i (1998)     larging the tax base. As a share
                                                                                                                                                           of total personal health care ex-
    Note. $PPP=purchasing power parity; MRI=magnetic resonance imaging unit.                                                                               penditures, French NHI funds fi-
      Organization for Economic Cooperation and Development (OECD) Health Data has traditionally published a figure of around 6 physician
    consultations per capita for the United States. According to the 2002 edition, this figure is based on the National Health Interview Survey of the     nance 75.5%, supplementary
    National Center for Health Statistics. This source, however, includes telephone contacts with physicians, as well as contacts with physicians in       private insurance covers 12.4%
    hospital outpatient departments and emergency rooms (ERs). The French figure includes consultations with all physicians in private practice            (7.5% for the nonprofit sector
    including health centers (5.4) and home visits by physicians (0.6). It excludes all telephone contacts and hospital outpatient and ER
    consultations. Thus, to obtain comparable data, the US figure is taken from the National Ambulatory Medical Care Survey (NAMCS), a survey of           mutuelles and 4.9% for commer-
    visits to physicians’ offices, hospital outpatient departments, and ERs. According to the 1995 NAMCS, visits to physician offices account for 81%      cial insurers), and out-of-pocket
    of ambulatory care use, and visits to emergency rooms and hospital outpatient departments account, respectively, for 11.2% and 7.8% of                 expenditures represent 11.1%.44
    ambulatory care use. Taking these proportions into account, as well as the fact that patients are seen by physicians in only 71% of outpatient
    department visits, the 1999 per capita rate of physician visits would only increase to 3.04.                                                              Physicians in private practice
      Source. CREDES.20                                                                                                                                    (and in proprietary hospitals) are
      Source. National Center for Health Statistics.19 (These figures exclude federally employed physicians as well as all anesthesiologists,              paid directly by patients on the
    pathologists, and radiologists.)
      Source. OECD.27                                                                                                                                      basis of a national fee schedule.
      Source. Ministry of Health and Social Affairs.28                                                                                                     Patients are then reimbursed by
      Source. National Center for Health Statistics.29                                                                                                     their local health insurance
      Source. National Center for Health Statistics.30
      These figures, cited in Reinhardt et al,31 understate differences in the per capita volume of prescription drugs sold because increases in drug      funds. Proprietary hospitals are
    prices have been significantly higher in France than in the United States since 1980. When expenditure data on prescription drugs in France            reimbursed on a negotiated per
    and the United States are adjusted by the OECD index of pharmaceutical price inflation in both nations, the volume of prescription drug                diem basis (with supplementary
    purchases in France exceeds that in the United States by a factor of 2. Source: OECD Health Data 1999, cited in S. Chambaretaud.26
     Source. OECD Health Data 2001.                                                                                                                        fees for specific services) and
                                                                                                                                                           public hospitals (including pri-
                                                                                                                                                           vate nonprofit hospitals working
   The private hospital sector in                    have developed a strong capac-                         agement and quality assurance                  in partnership with them) are
France (both nonprofit and pro-                      ity for cardiac surgery and radi-                      activities.                                    paid on the basis of annual
prietary hospitals) has 36% of                       ation therapy.                                                                                        global budgets negotiated every
acute beds, including 64% of all                        The number of nonphysician                          FINANCING AND                                  year between hospitals, regional
surgical beds, 32% of psychiat-                      personnel per bed is higher in                         PROVIDER                                       agencies, and the Ministry of
ric beds, and only 21% of med-                       public hospitals than in private                       REIMBURSEMENT                                  Health. As for prescription
ical beds.24 The nonprofit sec-                      hospitals; in the aggregate, it is                                                                    drugs, unit prices allowable for
tor, which operates only 9% of                       67% lower than in US hospitals                            In 2000, roughly half of                    reimbursement under NHI are
all beds, has over 44% of pri-                       (Table 2). This difference in hos-                     French NHI expenditures were                   set by a commission that in-
vate long-term care beds.24 Pro-                     pital staffing may reflect a more                      financed by employer payroll                   cludes representatives from the
prietary hospitals, typically                        technical and intense level of ser-                    taxes (51.1%) and a “general so-               Ministries of Health, Finance,
smaller than public hospitals,                       vice in US hospitals. It also re-                      cial contribution” (34.6%)                     and Industry.
have traditionally emphasized                        flects differences between an                          levied by the French treasury on                  In contrast to Medicare and
elective surgery and obstetrics,                     NHI system and the US health                           all earnings, including invest-                private insurance in the United
leaving more complex cases to                        system, which is characterized by                      ment income.43 (Remaining                      States, where severe illness usu-
the public sector. Over the past                     large numbers of administrative                        sources of financing for the                   ally results in increasing out-of-
15 years, however, although                          and clerical personnel whose                           CNAMTS and its affiliated                      pocket costs, when patients be-
there has been no change in its                      main tasks focus on billing many                       health insurance funds included                come very ill in France their
relative share of beds, the pro-                     hundreds of payers, documenting                        payroll taxes on employees                     health insurance coverage im-
prietary sector has consolidated,                    all medical procedures per-                            [3.4%], special taxes on automo-               proves. For example, although
and many proprietary hospitals                       formed, and handling risk man-                         biles, tobacco and alcohol                     coinsurance and direct payment

34 | International Perspectives Forum | Peer Reviewed | Rodwin                                                                    American Journal of Public Health | January 2003, Vol 93, No. 1
                                                   INTERNATIONAL PERSPECTIVES FORUM 

is symbolically an important part         drugs. Owing to strict controls on      the United States. Add to this the      early 1970s.52 Much like the pro-
of French NHI, patients are ex-           capital expenditures in the health      enormous choice of health deliv-        spective payment system for
empted from both when (1) ex-             sector, France has fewer scanners       ery options given to consumers,         Medicare in the United States,
penditures exceed approximately           and magnetic resonance imaging          the low level of micromanage-           France has imposed strong price
$100, (2) hospital stays exceed           units than the United States. But       ment imposed on health care             control policies on the entire
30 days, (3) patients suffer from         France stands out as having             professionals, and the higher           health sector. Greater cost con-
serious, debilitating, or chronic         more radiation therapy equip-           level of population health status       tainment has been achieved
illness, or (4) patient income is         ment than the United States,            achieved by the French, and             through such controls in France
below a minimum ceiling,                  Japan, and the rest of Europe.          some would argue that the               than in the United States.32
thereby qualifying them for free             In contrast to Great Britain         French model is a worthy export             Although the level of health
supplementary coverage.                   and Canada, there is no public          product. Others, however, would         services use is high in France
    Charges for services provided         perception in France that health        emphasize the problems that ac-         (Table 3), prices per service unit
by health professionals—whether           services are “rationed” to pa-          company this model.                     are exceedingly low by US stan-
in office-based practice, in outpa-       tients. In terms of consumer satis-         First, despite the achievement      dards, and this has led to increas-
tient services of public hospitals,       faction (Table 1), a Louis Harris       of universal coverage under NHI,        ing tensions (physicians’ strikes
or in private hospitals—are nego-         poll placed France above the            there are still striking disparities    and demonstrations) between
tiated every year within the              United Kingdom, the United              in the geographic distribution of       physician associations and their
framework of national agree-              States, Japan, and Sweden.7 A           health resources and inequalities       negotiating partners—the NHI
ments concluded among repre-              more recent European study re-          of health outcomes by social            funds and the state. The allow-
sentatives of the health profes-          ports that two thirds of the popu-      class.45,47,48 In response to these     able fee for an office visit to a
sions, the 3 main health                  lation is “fairly satisfied” with the   problems, there is a consensus          GP, for example, is only 20 €,
insurance funds, and the French           system.8                                that these issues extend beyond         and one half of all French physi-
state. Once negotiated, fees must            France also ranks high on            health care financing and organi-       cians are GPs. Physician special-
be respected by all physicians ex-        most measures of health status          zation and require stronger pub-        ists also receive low fees (23 €),
cept those who have either cho-           (Table 1). A recent report by the       lic health interventions.49             except for cardiologists (46 €),
sen or earned the right to engage         Organization for Economic Coop-             Second, there is a newly per-       psychiatrists (36 €), and those
in extra billing, typically special-      eration and Development                 ceived problem of uneven qual-          who do not accept assignment.
ists located in major cities. In-         (OECD), for example, indicates          ity in the distribution of health       The $55 000 average net annual
deed, in Paris, up to 80% of phy-         that France is well above the           services. In 1997, a reputable          income of French physicians—
sicians in selected specialties           OECD average on a range of key          consumer publication issued a           salaried hospital-based doctors as
engage in extra billing, in con-          indicators.12 A more critical view      list of hospitals delivering low-       well as GPs and specialists in pri-
trast to the national average of          would emphasize that France has         quality, even dangerous care.50         vate practice—is barely one third
20% among general practition-             high rates of premature mortality       Even before this consumer               that of their US counterparts
ers (GPs). In consulting these            compared with the rest of Eu-           awareness, there was a growing          ($194 000)53,54 (C. LePen and E.
physicians, patients are reim-            rope, but most analyses of this         recognition that one aspect of          Piriou, written communication,
bursed only the allowable rate by         phenomenon suggest that it has          quality problems, particularly          August 2002). In addition to
NHI; supplementary insurance              less to do with health care ser-        with regard to chronic diseases         price controls, capital controls on
schemes cover the remaining ex-           vices than with inadequate pub-         and older persons, is the lack of       the health system are stringent.
penditures, with different limits         lic health interventions to reduce      coordination and case manage-           They include limits on the num-
set by each plan.                         alcoholism, violent deaths from         ment services for patients. These       ber of medical students admitted
                                          suicides and road accidents, and        problems are exacerbated by the         to the second year of medical
SERVICES, PERCEPTIONS,                    the incidence of AIDS.45,46             anarchic character of the French        school, controls on hospital beds
AND HEALTH STATUS                                                                 health system—what might be             and medical technologies, impo-
                                          ACHIEVEMENTS,                           called the darker side of laissez-      sition (since 1984) of global
   Existing data (Table 3)—               PROBLEMS, AND                           faire.51                                budgets on hospital operating ex-
whether they come from surveys            REFORM                                      Third, although, compared           penditures, and the more recent
or are byproducts of the adminis-                                                 with the United States, France          Juppé plan that imposed annual
trative system—indicate consis-              The French health care system        appears to have controlled its          expenditure targets for all NHI
tently that, compared with Amer-          delivers a higher aggregate level       health care expenditures, within        expenditures.
icans, the French consult their           of services and higher consumer         Europe, France is still among the           Prime Minister Juppé’s plan
doctors more often, are admitted          satisfaction with a significantly       higher spenders. This has led the       and more recent reforms have
to the hospital more often, and           lower level of health expendi-          Ministry of Finance to circum-          addressed the problems noted
purchase more prescription                tures, as a share of GDP, than in       scribe health spending since the        above; none of them, however,

January 2003, Vol 93, No. 1 | American Journal of Public Health                                  Rodwin | Peer Reviewed | International Perspectives Forum | 35
                                                  INTERNATIONAL PERSPECTIVES FORUM 

have been solved. The Juppé              out a “single-payer” system. To do     evidence in support of this                       Note. A bibliography in English on the
government established a slew            this, however, will still require a    proposition. Of course, it is easier          French health care system is available on
                                                                                                                              the author’s Web site at http://www.nyu.
of national public health agen-          statutory framework and an ac-         to achieve this model before the              edu/projects/rodwin/main.html.
cies to strengthen disease sur-          tive state that regulates NHI fi-      emergence of a powerful com-
veillance and monitor food               nancing and provider reimburse-        mercial health insurance industry
safety, drug safety, and the envi-       ment. Of course, French NHI was        such as exists in the United States           I thank the R. W. Johnson Foundation
ronment.55 It organized a new            not designed from scratch as a         today. Nevertheless, so long as               for a Health Policy Investigator Award
                                                                                                                              that enabled me to explore this topic
national agency, the Agence Na-          pluralistic, multipayer system pro-    NHI covers the insurance func-
                                                                                                                              and others.
tional d’Accréditation et d’Évalu-       viding universal coverage on the       tions, why prevent the private in-                I am grateful to Dr Robert Butler,
ation en Santé, to promote               basis of occupational status. It is    surance industry from providing               president and CEO, ILC-USA, and to my
                                                                                                                              colleagues in the New York Group on
health care evaluation, prepare          the outcome of sociopolitical          useful services, on a contractual
                                                                                                                              Rekindling Health Care Reform for
hospital accreditation proce-            struggles and clashes among            basis, under a NHI program?                   sponsoring the seminars and lecture on
dures, and establish medical             trade unions, employers, physi-           Fourth, coverage of the re-                which this article is based and for help-
                                                                                                                              ful discussion during its preparation. I
practice guidelines.56,57 It also        cians associations, and the state.     maining 1% of the uninsured in
                                                                                                                              thank Claude LePen, William Glaser,
set up regional hospital agencies        This suggests that NHI in the          France suggests that national re-             Michael Gusmano, and Marc Duriez for
with new powers to coordinate            United States could similarly          sponsibility for entitlement is               their insights; Birgit Bogler, Gabriel
                                                                                                                              Montero, and Eric Piriou for precious re-
public and private hospitals and         emerge from our patchwork accu-        more equitable than delegating
                                                                                                                              search assistance; and 3 anonymous
allocate their budgets.58                mulation of federal, state, and em-    these decisions to local authori-             French reviewers for provocative and
   In addition, the Juppé plan in-       ployer-sponsored plans so long as      ties. This lesson is consistent with          thoughtful comments.
cluded measures to modernize             we recognize the legitimate role       the experience of Medicare ver-
the French health care system by         of government in overseeing the        sus Medicaid in the United States,            References
improving the coding and collec-         rules and framework within             as exemplified by the differences             1. World Health Report 2000. Avail-
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                                                                                About the Author                              wood). 1990;9(2):185–192.
avoid at home. It is thus a risky        lic programs.
                                                                                Victor G. Rodwin is with the Wagner           8. Mossialos E. Citizens’ views on
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                                                                                the International Longevity Center-USA.
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                                                                                                                              9. de Kervasdoué J. Pour une Révolu-
                                                                                                                              tion sans Réforme. Paris, France: Galli-
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36 | International Perspectives Forum | Peer Reviewed | Rodwin                                     American Journal of Public Health | January 2003, Vol 93, No. 1
                                                        INTERNATIONAL PERSPECTIVES FORUM 

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