Résumé du papier en
français
Quelques soins de santé aux États-Unis et en France sont
les mêmes et quelques autres sont différents. Les États-Unis pourraient
apprendre du système de santé en France. Aux États-Unis, les soins de santé
sont très chers, donc il est préférable que ce système change. En France, la
plupart des assurances soins de santé et hôpitaux sont à but non lucratif. Pour
cette raison, l’accent est mis sur les soins de santé et pas sur l’argent. Les
deux systèmes de soins de santé sont financés par les employeurs privés et le
gouvernement. Ceci a bien fonctionné en
France, mais à cause du système, certains pensent que ceux qui travaillent
méritent beaucoup plus les soins de santé que ceux qui sont au chômage. Les États-Unis
font face aux problèmes de paiement pour la formation des médecins. Ces
universitaires qui obtiennent leur licence, préfèrent plutôt travailler dans le
secteur privé. Les actionnaires font des bénéfices et les contribuables ne sont
pas remboursés. Pas toutes les politiques de la France marcheront pour les
États-Unis, mais il y en a beaucoup qui pourraient être adoptées.
Introduction
Paper abstract in English
The healthcare
in the U.S. and France is the same and different. The United States could learn
from France’s healthcare system. In the U.S. healthcare is very expensive; so,
the system needs to change. In France, most healthcare insurance and hospitals
are nonprofits. Because of this, the focus is on healthcare and not money. Both healthcare systems are funded by private employers and
the government. This has been working well in France, but because of the system
some people think people who work deserve healthcare more than those who are
unemployed.
The U.S. also faces problems with paying for doctors’
training and university research only to find the graduates work in the private-sector. Then
stockholders profit and taxpayers don’t get a return on their money. Not all of France’s policies will
work for the U.S., but there are many that could be adopted.
Introduction
There has been a lot of debate over
the recent changes to healthcare in the U.S., both laws that have been
implemented and those that will start in 2014. In many discussions among
legislators, citizens and the media, comparisons to other countries’ healthcare
systems color the debate. Many people have compared proposed polices to healthcare
in Canada and England; and some have compared America’s system to France. This
paper focuses on the similarities and differences between the U.S and French
healthcare systems and what the U.S. could learn from France and the policies
the U.S. could possibly adopt in the future. What policies that could translate
successfully are largely dependent on the shared history of the countries.
Both countries have similarities, the main one being that both have public and private healthcare co-existing and working together. Another parallel is the countries’ system linking healthcare to work, which has created inequalities in both countries. Indeed, aspects of French healthcare that are successful are worth consideration in the U.S.
Both countries have similarities, the main one being that both have public and private healthcare co-existing and working together. Another parallel is the countries’ system linking healthcare to work, which has created inequalities in both countries. Indeed, aspects of French healthcare that are successful are worth consideration in the U.S.
Healthcare in the United States and France
In 2000, the World Health
Organization ranked 191 countries’ healthcare systems by life expectancy and
access to healthcare. France came in first; the United States 37th (WHO,
Shapiro). The U.S. ranked below Costa Rica but above Slovenia (Edelberg). Other
researchers measured the "amenable mortality," a measure of deaths
that could have been prevented in 19 industrialized nations: France came in first;
the United States was last (Shapiro).
In France, life
expectancy is 81 years; infant mortality is 4 per 1,000 live births; health
spending as a percentage of GDP is 11 percent; percentage
of health spending that is private is 20 percent (World Health Organization); and for every doctor there are 430 people (Cline).
In the U.S., the life expectance at
birth was 76 and 81 years for males and females respectively in 2009. The total
expenditure on health per capita in 2010 was $8,362, or 17.9 percent of GDP (WHO).
In the U.S., there is a doctor for every 1,230 residents
(Cline).
While many lump Europe together as having
“socialized medicine,” each European country has a different system. Historian at
Northern Arizona University, and author of the book Differential Diagnoses: A Comparative History of Health Care
Problems and Solutions in the United States and France, Paul Dutton asserts, “The French don't
consider their system socialized. In fact, they detest socialized medicine” (Shapiro).
In fact, Frances’s system shares many similarities to the U.S. system (Dutton).
However, there are also a lot of differences. Both counties could stand to
learn from each other as they face some of the same challenges, such as an
aging population and concern that the systems are fiscally unsustainable.
To better understand the systems,
the debate, and what could work in the future, it is important to look to
history to understand how healthcare became what it is today. Dutton says the
French and the Americans want choice. He claims these shared values come out of
a shared history: "Both countries are products of Enlightenment-era
revolutions.” Dutton asserts, "The French hold individual liberty and
social equality very dear ... 'liberty, equality, and fraternity. [...] And in
this country [the United States], of course, we have similar ideals: individual
liberty, social equality — equal chances for everyone." (Shapiro)
Both France and the United States
have systems that are a combination of employer and government-sponsored,
public and private. France has been effective setting up a healthcare system
where the public and private sector compete to provide the best service. Also
in France, the majority of hospitals are nonprofit. Health insurance doesn’t
have stockholders looking for increasing dividends. Instead, the goal is health
rather than profit. This puts the incentives in the right place to align with the
goal of quality healthcare. It is important to set up the system so that incentives
are in the right place so that doctors are free to give the best care possible.
This is why many doctors supported pay-for-service plans in the past rather
than managed care like in Great Britain and HMOs in the U.S. (Dutton)
The two-class system
Another thing to consider in the
healthcare debate is how the system shapes our understanding of modern-day
healthcare. In both France and the U.S., by linking healthcare to the employer
it creates a dynamic in which the public views patients as “deserving” and
“non-deserving” based on their employment status (Dutton 11, 203). Historically,
and carried over to today, the system disproportionally leaves women and
minorities with fewer options and less quality care as compared to their white
male counterparts. Dutton asserts:
Its
ugly underside was the belief that many citizens who, through no fault of their
own, lacked access to workplace health insurance were "less
deserving" of health security […] This development had a particularly
negative impact on women and minorities, who were (and are) much more likely to
be considered "less deserving.” (Dutton 11)
Equality is an issue that should be
addressed in both the U.S. and France. Both systems should implement policies
to reduce having a two-class system.
As health insurance developed in the
U.S., African American and Latino farm workers were not given health insurance
through their work (Dutton 139-40). Likewise, women working in garment
factories didn’t receive health insurance as there was more supply of labor
than demand in clothing industry (Dutton 140). This made women and children
vulnerable. “In the event of divorce or insufficient disposable income for
supplemental insurance premiums, women and children were usually the first to
lose health security” (Dutton 140). “In this way, federal tax policy not only
played a major role in the growth of employment-based voluntary health
insurance, it also contributed to its class inequalities” (Dutton 140).
Dutton argues, “France’s comparable
historical tradition of workplace health coverage underlies inequities of
health care access because of the continued importance of supplemental
insurance.” In 1995 in France, 83 percent of its citizens were covered by
health insurance; however, only 68 percent of skilled wage earners had
supplemental insurance compared to 90 percent of white-collar managers. (Dutton
203)
In 1990, the life expectancy of
white people in the U.S and France was the same (Dutton 190). However, in the
U.S. African Americans had a life expectancy that was five years less, and 37
million Americans were uninsured (Dutton 190).
In 1954 in the U.S., the IRS made
group health insurance premiums tax deductible. While this increased employer
spending on health insurance, the most expensive and the best coverage went to
those with the highest incomes (Dutton 140). This gave the wealthiest workers, who
were in a higher tax bracket, a larger tax break than their low-wage
counterparts. The same tax inequality is true of Medicare as well; it is paid
for through a regressive tax.
France’s Sécurité Sociale similarly
has policies that promote inequality. Dutton asserts: “[T]he continued reliance
on payroll levies that took a flat percentage of workers’ wages without regard
for their overall income reinforced the inequality of health care financing” (153).
Also, 99 percent of French workers have a health insurance tax come out of
their wages, but there is no tax on income that comes from rent and investments,
but the landlords and investors still enjoy insurance (Dutton 201). This is
eerily similar to the U.S. tax code charging 15 percent on income coming from
stock investments, when the individuals who earn the most from this would
likely be in the 35 percent tax bracket.
Why the cost has gone up
Advances in medicine made it
possible for people to live longer, but it also costs money. Dutton explains:
By
1980, with fifteen thousand operations a year, the near-miraculous procedure of
open-heart surgery had become almost mundane in France. For a short time, the
public marveled at this stupendous advance in cardiology, but the price of it
all escaped them. In 1980, open-heart surgery cost more than seven times the
maximum annual Sécurité Sociale contribution, an amazing statistic if one
remembers that only sixty years earlier, medical bills were deemed a
practically inconsequential burden of illness. (160)
Post World War II, people also
started viewing medicine differently. Instead of going to a doctor when they
were sick, people wanted to go to become healthier. Dutton explains, “[H]ealth
was no longer simply the absence of illness, but rather, as the World Health
Organization first put it in 1946, ‘a state of complete physical, mental and
social well-being.’” (119-20)
Part of this change was also because
people had already paid for the health insurance, so there wasn’t a cost
incurred to them for visiting the doctor. In France, second and third medical
opinions became more common (Dutton 159). In France, the term coined le nomadisme medical, described patients
who went to even a fourth specialist for the same condition “all of which were
covered by Sécurité Sociale without question” (Dutton 160).
In the U.S., to help curb the costs
of people overusing care, President Reagan wanted patients to pay more for
their expenses. However, physicians pointed out that patients were not
sufficiently knowledgeable consumers. Patients might think twice about visiting
the doctor because they think something isn’t serious when it might be
something that could be treated easily if caught right away, but if they waited
until it turned worse it could become both serious and costly. While
laissez-faire economics can work to improve products and services and bring
prices down in other areas, with medicine it’s different because since
consumers don’t know when it’s most cost-effective to visit the doctor or which
tests are important because they don’t have a medical education—they aren’t
doctors (Dutton 173)
Suggestions for U.S.
healthcare
Policies to improve healthcare in
the U.S. could include lowering the cost of liability insurance to physicians. When
doctors feel compelled to practice “defensive medicine” it raises the cost of
healthcare and doesn’t help the patient (Dutton 23).
Research should be funded by the
government instead of privately. The U.S. could also pool its resources with
other first-world countries that can afford it. This way, the projects that get
funded will be what is best for society rather than what is best for the bottom
line. This will prevent U.S. taxpayers from subsidizing university research
sold to private companies that charge exorbitant fees to tax-payers when they
get sick and large dividends to shareholders (Frangioni 503). Not only is it
corporate welfare, but it also prevents innovations that can cure the sick but
aren’t a good investment from a business standpoint. With money going towards
research that has successfully found cures to diseases, it makes no sense from
an ethical standpoint to let people die because of unfavorable markets
(Frangioni 504). Frangioni asserts:
Historically,
academic medical centers (AMCs) were places where the next generation of
physicians was being trained (with the help of US government subsidies; while
fundamental research into the prevention, mechanism and treatment of human
disease was being conducted (again, with the help of US government subsidies).
[…] Should all decisions in the pipeline, from discovery to delivery of a new
device, diagnostic product or therapy, be based on maximizing profit when, in
fact, US taxpayers have directly or indirectly funded nearly every major
discovery in medicine over the past 40 years? (Frangioni 504)
Professors should also be paid more
and there should be stricter laws to stop taxpayers from subsidizing industry
through university research. According to Frangioni, many physicians are
trained by AMCs with U.S. tax-payer money only to work for for-profit companies
that didn’t have to invest money in the researchers’ training, but reap the
rewards of the medical discoveries. Paying professors more would help retain
them at the universities. A similar phenomena happens with the U.S. military
and private contractors: The government invests millions of dollars but never
see its investment realized as trainees move to the private sector that pays
better because it didn’t have to invest in talent (Maddow).
Everyone should receive healthcare
in the country as well as anyone visiting the country who needs healthcare.
However, people can pay out-of-pocket or with supplemental insurance for luxuries
such as private rooms or brand-name drugs. Incentive to work is important, but
morally everyone deserves first-class healthcare.
There should also be more
preventative medicine. This would reduce costs in the long run.
Costs should be reasonable, but a
token co-pay would make people value the service more. There should also be a
higher co-pay for emergency rooms so people don’t take advantage of them out of
convenience when they could wait until business hours (i.e., a visit for a
cold).
A goal should be set to achieve 90
percent of health insurance to be nonprofit and 90 percent of hospitals to be
nonprofit. When the goal of an institution is on care rather than profit, the
care changes to best accomplish the goal: making people well. This would avoid
unnecessary tests that are highly reimbursed. “[W]ith fewer machines comes less
of a financial incentive to keep them running at a profit” (Neel). This change
would also drastically reduce the need for doctors to practice defensive
medicine (fearing litigation and running unnecessary tests out of fear of being
sued). [T]his is not an important issue in France. […] [S]ince 2002 there has
been a national no-fault compensation scheme” (Rodwin). The non-profit change
of incentives puts physicians in a less precarious place in other ways. Dutton
explains:
In
the U.S., An HMO-employed primary care physician who exceeds target referral
rates to specialists often faces an annual salary deduction that has been
agreed on in advance. A PPO network physician who orders costly diagnostic
testing that surpasses agreed-on utilization rates faces the possibility that
the managed care insurer may not renew her contract. (181)
The U.S. should adopt France’s card
system. Each French citizen has a green carte vitale
(literally a "life card" or social security card) (Cline). By having patients’ health history and
banking information on a scannable card, nurses don’t have to ask questions and
enter in data over and over again, paper is saved, time is saved and the
information is more accurate. Unnecessary tests don’t have to be run or shots
given. There are less administrative costs associated with billing. And, with
an increasingly mobile workforce, paperwork doesn’t need to be photocopied and
forwarded. Some people in the U.S. might feel like the government was spying on
them, but they can get over it when they see how convenient it is.
Costs of going to medical school
should not go up. Things are being done to address this should continue to do
so. While medical school is free in France and most other countries, in the
U.S. new M.D.s can be $150K or even $200K in debt. This puts pressure on
students to specialize where they can three times as much money in order to pay
off their debt, even if they wanted to go into family practice.
More of an emphasis should be put on
public health in order to prevent problems before they happen. This would also
save a lot of money in the long run.
Conclusion
Healthcare, history and people are complex,
but the U.S. should look to France to identify policies that are working that
could also be translated to the U.S. given the U.S.’s differences from France. Other
aspects of healthcare that are working well should be left alone. Different
systems work better for different countries, but if there are positive aspects
in a system that might work in a system where things aren’t working as well,
why not give it a try?
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