French and the United States Health Care Systems H 533 – Fall 2008 Group Project – Critical Comparison Sarah Stark, Joe Fisher

2 French and the United States Health Care Systems Liberté, égalité, fraternité Life, liberty, and the pursuit of happiness Sécurité Sociale Employment based voluntary health insurance

3 Health Insurance Europe/France Early Years Germany, under Chancellor Bismarck (1883) Other countries (late 1800's, early 1900's) France (1910) – Mutual Aid Societies Britain (1911) World War I ( ) – Alsace-Lorraine (1919) – Social Insurance and Medical Charter (1930) World War II ( )

4 Health Reform USA Early Years American Association of Labor Legislation (1907) – The 1915 AALL bill and battle ( ) US enters World War I ( ) Great Depression (1929 – 1939) – FDR's 2nd Deal: Social Security Act (1935) World War II (1939 – 1945) – Senator Wagner's Health Bill (1939, 1943) – Truman's Proposed Health Program (1945)

5 Health Insurance France Recent Years Sécurité Sociale (1945): ~50% – Mutual Aid Societies: Supplemental Insurance Charles de Gaulle (1960): ~76% Great reform (1980): ~99% Universal Coverage (2000): ~100% (2005) 11.2% GDP, ~ $0.25 trillion, $3,926 per person

6 Health Reform USA Recent Years Wage Funded and Fraternal Orders Blue Cross (1930) and Blue Shield (1940) Medicare/Medicaid (1965) HMO's (1973) and PPO's EMTALA (1986) and SCHIP (1997) (2005) 15.2% GDP, ~ $2 trillion, $6,347 per person

7 France and the United States Health Care Funding Source: Jean de Kervasdoué, ed., Le Carnet de santé de la France en 2000, note, p. 89; Blue Cross Blue Shield Association, Medical Cost Reference Guide, p. 30. France United States

Analyzing the French Health System Harvard-Harris-ITF (1990). Ten Nation Survey Eurobarometer (2003) The Commonwealth Fund (2007) Publics View of Their Health System Satisfaction Indicators France 1990 France 2003 United States 1990 United States 2007 Fundamental Changes Needed 42% 25.5%60%48% Completely Rebuild the System 10%7%29%34% Minor Changes Needed 41%41.9%10%16%

Comparison of Access Indicators Indicators of AccessFranceUSA Percent with health coverage, excluding under insured 99.8%65% Percent of chronically ill who report lack of care: Access problem because of cost ( Commonwealth Fund 2008 ) 23%54% Rank for Distribution of Health in Population ( WHO 2000 ) 1232 Weiz, D. Gusmano, M.K., Rodwin, V.G., & Neuberg, L.G. (2007)

Comparison of Quality Indicators Quality IndicatorFranceUSA Rank of Responsiveness ( WHO 2002 )161 Percent of Chronically Ill who reported lack of care due to Coordination Problems ( Commonwealth Fund 2008 ) 22%34% Percent of Chronically Ill reporting Medication, Medical or Lab Error ( Commonwealth Fund 2008 ) 18%34% Mortality Amenable to Health Care: Deaths preventable with care ( Commonwealth Fund 2008 ) 65 per 100, per 100,000

Comparison of Financial Indicators Financing IndicatorsFranceUSA Fairness in Financing Rank ( WHO 2000 ) Health care Spending per capita Rank ( WHO 2000 ) 41 Out of Pocket Payment as % of National Private Expenditure on health ( WHO 2005 ) 33.2 %23.9 % Total expenditure on Health per capita ( WHO 2005 ) $3,819$6,350 Health Care Expenditure as percentage of GDP ( WHO 2005 ) 11.2%15.2%

Strengths of the Systems France Universal coverage Coverage for health prevention and emphasis on general practice Complementary health incorporated into system High degree of consumer choice United States Innovative technologies, medications and treatments encouraged High-quality services available for those with good insurance or enough personal resources At the forefront of clinical and technological breakthroughs for numerous diseases Large number of specialists

Weaknesses France Future of financial sustainability unknown Decision-making and governance requires participation from several parties, and can be time- intensive Cost-control is difficult United States Barriers to health care increasing High costs, cost-shifting and insurance pools No emphasis on general practice, preventive health or complementary health approaches Little choice

14 Lessons from France 1. Universal coverage possible without “single payer” system. 2. Universal coverage can be achieved without “Big Bang” reform. 3. Universal coverage can include private insurers in supplemental insurance market. 4. National responsibility for entitlement may be more equitable than leaving decisions up to local authorities. 5. Financing universal coverage can be solved before meeting modernization and reorganization challenges. Rodwin, Victor G. (2006). The health care system under French National Health Insurance: Lessons for health reform in the United States. Universal Health Insurance in France: How Sustainable? Essays on the French Health Care System. Washington DC, Embassy of France, 2006.