As that rare beast, a French free marketer, I have been looking at the healthcare debate in the US with mixed emotions. Sometimes bemused detachment. Sometimes anxiety, as I know how much European healthcare depends on American innovations.
As the debate has unfolded, I have been thinking about how the healthcare system I enjoy and the US healthcare system, the way I’ve seen it portrayed, work.
The French healthcare system is one of the few things we get to be justifiably proud of. It is relatively cheap. It avoids many (though by no means all) of the dysfunctions involved with other “government-run” healthcare systems. It covers everyone, and covers them pretty well all else considered. Given France’s demographic profile it probably isn’t sustainable over the long run, and looks set for either catastrophic collapse or drastic scaling back twenty years from now, depending on our politicians’ maturity. But as of right now, I think it’s fair to say that it is one of the very best, if not the best, healthcare system in the world.
Meanwhile, the US healthcare system (and there are actually US healthcare systems, between private insurance, Medicare, the VHA, etc.), though mind-bogglingly complex, has much going for it. There’s little doubt that the world’s top hospitals and medical practitioners and researchers are mostly in the US. The vast majority of Americans are actually happy with the healthcare they get. That said it also has dramatic flaws. Even though many figures bandied about by reform proponents are flawed, it is still, I believe, hardly justifiable to have so many uninsured. It is rife with inefficiencies.
But the one thing that struck me the most through this debate is how actually similar the two systems are.
The French healthcare system is actually mostly employer-based (a criticism often leveled at the US system). I get coverage through my school (students pay a fee to one of several public, but competitive firms that provide coverage for students) and, because I’m under 25, through my parents. As an entrepreneur, once I get married, I will get coverage through my wife.
The French healthcare system hasn’t always been universal. The CMU, our version of Medicare-for-all, actually came into force in 2000. Between Hillarycare and LBJ-era proposals, an alternate universe where Americans got universal healthcare before Frenchmen is a not-outlandish-at-all proposition.
The French healthcare system is actually quite free market, or at least competitive. There are private hospital chains listed on the French stockmarket, just as in the US, and unlike many other European countries. A publicly-run, tax-financed insurance scheme provides basic coverage to everyone, but most workers and their families (and retirees with savings) get top-ups through private, employer-provided insurance. You can buy insurance outside of your employer, too. Insurers (public and private) compete, private hospitals compete, doctors (not yet pharmacists) compete.
It is all very regulated, often haphazardly so, but then again that’s also true of the US system.
So, why does it work so well in France and so badly in the US? (Insert here caveats about how the French system really isn’t so great and the US system really not so bad, all true.)
I think the big thing is that the French system is much cheaper. Drug are cheap because of price controls, collective bargaining and lower GDP. French doctors make very little money relative to their studies.
As an aside, I am retrospectively struck by how, growing up in an upper-middle class household, medical school was never considered an option for me. When I was a kid and grownups asked me what I wanted to do when I grew up, I was suggested lawyer, engineer, journalist, high functionary (vive la France…), but never doctor, and when I was looking at colleges and majors, the idea never even came up. French doctors go to school for at least a decade in ghastly conditions (there are no grandes écoles for medicine, so it’s all done in derelict public universities), are underpaid until their thirties, work punishing hours, and unless they’re in lucrative specializations, work in a private hospital, or have a general practice in a wealthy place, make relatively good money but nothing great. Incidentally, starting a business was never a popular choice either.
It’s hard to imagine these characteristics being imported in the US. Even putting aside for a second the formidable lobbying might of the pharmaceutical and medical professions, there’s good evidence that turning drugmaking into a low-margin, utility business would kill medical innovation, and that we don’t want medical school to become a low/negative ROI proposition for bright young students.
So is the French system really the US system only much cheaper and with a sorta-public-option? Maybe, maybe not. Beyond these broad characteristics, not being an expert, I can’t really make an informed judgment.
But I felt that pointing this out might illuminate a couple things, mainly the following: first of all, that while it’s sometimes useful to draw stark contrasts between alternatives, it can be even more useful to realize that they may not be so different after all. The US system isn’t nearly as “free market” as some seem to believe; the French system isn’t nearly as “socialized” as some fear (or others might like). The second thing that’s interesting, in my view, is how often the devil is in the details.
If so much of the basic framework of the US and French systems is the same and the result is so different, perhaps the answer isn’t to overhaul either one but to take a granular view and smartly shift a few things here and there. This might have important ramifications for most public policy, I think.