The French health care system is increasingly cited as an example
overseas. In his latest film, Sicko, Michael Moore seems to
regard it as a solution to the problems affecting the U.S. health care
system. However, the French system, relying on a mandatory public health
insurance monopoly, is far from a panacea.
First, it is illusory to think of it as a solution for controlling
health expenditures.
In France, successive plans in the 1980s and 1990s for rationalizing the
public health insurance system, as well as the more recent cost
containment reforms in 1996 and 2004, have simply failed to deliver.
Since 1988, health accounts have regularly been in the red, with
deficits reaching many billions of euros.
In the 1996 reform, the government imposed cost containment measures on
public health spending based purely on accounting considerations. This
was named the “national target for health insurance spending” (known by
the French acronym ONDAM). Nevertheless, deficits accumulated from 1997
to 2006, reached more than 49 billion euros (adjusted for inflation).
This was twice as much as deficits in the previous decade when these
cost control measures did not exist.
To prevent further overspending beyond the ONDAM, a new Warning
Committee was set up as part of the 2004 reform. The Committee is
supposed to sound the alarm once health expenditures begin again to get
out of hand. And that’s exactly what it did, on 29 May, judging that
there is “a serious risk of overspending”. Despite decades of a public
heath insurance monopoly, health expenditures are obviously still out of
control in France.
But there is something worse than ineffective controls over public
health expenditures.
Instead of relying on greater individual responsibility, broader choice
and more competition in the health insurance field, thereby providing
real incentives to cut on costs where it is truly relevant, regulations
have instead proliferated in France with the aim of controlling the
overall health care system.
However, such regulations are the source of increasing bureaucratisation
of the system, with its own pernicious effects on patients and health
care professionals.
Patient choice, the freedom for private-office-based physicians to
practise and the existence of private funding and private health care
providers clearly make the French system attractive to many Americans.
These are indeed the pillars that guarantee better health care for the
French, without waiting lists of the sort found in countries where the
health care system is completely under state control, as in the U.K. or
Canada.
However, following the mirage of public cost containment, these pillars
are being questioned increasingly, with the risk that French patients
may face the same shortages and waiting lists as in some other
countries.
For example, even if it is not yet obligatory, a new “coordinated care
pathway” scheme encroaches on patients’ freedom to select medical care
from the physician or specialist of their choice. Before consulting a
specialist, patients are required to consult their attending physicians
first, just as occurs with general practitioners serving as gate-keepers
in the Canadian and British systems.
In the event of non-compliance with the new regulation, there are
provisions for financial sanctions for the insured. Following the latest
statement from the Warning Committee, the National Sickness Fund (CNAM)
has already announced higher financial penalties for patients not
complying with the “coordinated care pathway”.
Little by little, patient choice is on the way out. And unlike a
situation where there is competition, the insured do not have the choice
of opting for a competing insurance plan but must continue to pay their
taxes, even if they judge that those cost containment measures are of no
value to them.
Regulations affect health care providers as well. For example, the
freedom for private office-based physicians to choose the location where
they practise is being brought into question. Bureaucratic treatment
guidelines for sound medical practice can turn into means for
sanctioning physicians who do not comply with the official targets
limiting health expenditures. Rather than care for patients’ health,
physicians risk being obliged to change their practice solely to provide
savings for the public health insurance monopoly.
Conditions in clinics and hospitals are also increasingly regulated.
Since 2004, their financing has been based on a bureaucratically decided
payment structure (called “casemix-based financing”) for pathologies and
hospital stays that are categorized into supposedly homogeneous groups.
But the homogeneity of individual pathologies is a matter of degree, and
differences from one case to another can influence the cost of the
treatment for each patient. Ill-conceived homogeneous groups and
inappropriate bureaucratic fees could therefore lead hospitals to
discard pathologies or patients whose cost exceeds the financing
provided by public authorities.
When the entire health care system finds itself legally subjected to the
overall control of a centralising monopoly, patients are bound
eventually to suffer from its pernicious effects without having the
least choice in their health coverage or the way they get their health
care. Compared to the problems in the U.S. health care system, a
mandatory public health insurance monopoly “à la française” may
be tempting, but is not a good idea.
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