The heath care system U.S. and France
At the present time, there are debates over the problem of health care in the US and the main idea of which is that the US spends more on the health care than any other country in the world. Yet they still suffer from massive lack of insurance, uneven quality of service, and administrative waste. The dominance of the private sector over the public makes the US health care system unique. The French healthcare system has been in place and has continued to evolve for more than one hundred years, and was classified the “best health system in the world” by the World Health Organization (WHO) in June 2000.
It permits all French citizens access to treatment and to the latest discoveries in medical research. The success of the French health system is evident in the general health of the French population. Their life expectancy increases more than three months each year, and French women have the second highest life expectancy rate in the world. The research and comparison will reveal a current situation with health care systems in the US and France.
Health care in the United States, according to Wikipedia, is provided by many separate legal entities. The U.S. spends more on health care , both as a proportion of gross domestic product ( GDP ) and on a per-capita basis, than any other nation in the world.
Current estimates put U.S. health care spending at approximately 15% of GDP, which is the world's highest. The health share of GDP is expected to continue its historical upward trend, reaching 19.6 percent of GDP by 2016. The U.S. is the only major industrialized nation in the world lacking government-run or subsidized universal health care .
In the United States , around 84% of citizens have health insurance , either through their employer (60%), purchased individually (9%), or provided by government programs (27%; there is some overlap in these figures). Certain publicly-funded health care programs help to provide for the elderly, disabled, children, veterans, and the poor.Federal law ensures public access to emergency services regardless of ability to pay. U.S. government programs accounted for over 44% of health care expenditures, making the U.S. government the largest insurer in the nation. Americans without health insurance coverage at some time during 2006 totalled about 16% of the population, or 47 million people. Many individuals not covered by private insurance are covered by government insurance programs such as Medicare and Medicaid , various state and local programs for the poor, and the Veterans Administration , which provides care to veterans, their families, and survivors through medical centers and clinics. In 2006, Medicaid provided health care coverage for 38.3 million low-income Americans and Medicare provided health care coverage for 40.3 million elderly and disabled Americans. In 2003, total health spending per capita was $5,635, more than twice OECD average $ 2,307. Health insurance is expensive, and medical bills are overwhelmingly the most common reason for personal bankruptcy in the United States. American health care is provided by a diverse array of individuals and legal entities. Individuals offer inpatient and outpatient services for commercial, charitable, or governmental entities.
The French government provides a number of diverse and comprehensive healthcare rights. For more than 96 percent of the population, medical care is either
entirely free or is reimbursed 100 percent. Who provides health care in France? Everyone with employee (salary) status in France is covered by a national health insurance plan,known as securite sociale. Coverage extends to spouses and children without employee status themselves. People who are not entitled to securite sociale are required to take out special coverage, known as assurance personelle. Many people also choose to purchase additional insurance to complement or supplement the state-run program. France has a reputation for central direction but French healthcare is based on a compromise between
egalitarianism and liberalism. All citizens are said to be equal; yet, choice and competition are fiercely protected. The level of funding in public hospitals is determined by the government.
In France, hospitals have always been the core of the health care system. The number of hospital beds had decreased over time; it currently stands at 8.4 per 1000 inhabitants, which is close to European average. Hospitals can be roughly divided into two categories: public, and private for-profit.
The public sector represents about 65% of the beds. Public hospitals have specific obligations such as ensuring the continuity of care, teaching, and
training. They receive a budget which is largely based on historical basis.
Private for-profit hospitals concentrate on surgical procedures and rely mostly on fee-for-service reimbursement for their funding.
There are currently about 200,800 physicians in France, licensed to practice, and who also play a key role in political system. Half of physicians are specialists. Physicians and other professionals generally work in two kinds of environments: public hospitals and private practices. 25% of physicians work in public hospitals and another 11% work in other types of public establishments.
The financing of health care centers in the US around two streams of money: the collection of money for health care (money going in), and the reimbursement of health service providers for health care (money going out). In the United States, the responsibility for these two functions is shared by private insurance companies as well as the government, both of which are known in policy terms as “payers.” As such, the United States can be thought of as a “multi-payer” system.
Individuals and businesses
Taxes: Both individuals and businesses pay income taxes to the government. In addition, there is a payroll tax on employers and employees to finance Medicare.
Premiums: Businesses pay all or most of the premium for employer-based insurance for employees, and employees pay the remainder. On the individual
market, individuals pay for all premiums out of pocket. Employer-based insurance premiums and individual insurance premiums are collected by private insurers.
Direct or out-of-pocket payments: This is a direct payment to a provider for health care services (e.g. a co-payment).
Government
Medicare, Medicaid, S-CHIP, and the VA: The government uses money generated from taxes to reimburse providers who take care of patients enrolled in
these programs.
Public employees’ premiums: The government also uses tax dollars to pay private insurers a health insurance premium for federal employees and other
public employees.
Tax subsidy: There is a tax subsidy of employer-based insurance (not shown in the graph) that represents a major cost to the government (on the order of $100 billion). Employees receive health insurance benefits as tax-free compensation, and employers are able to deduct health insurance benefits as a cost of doing business. [Since employers are only taxed on profits, defined as any income above the cost of doing business, being able to deduct health insurance benefits as a cost of doing business is a tax subsidy for employers].
Private insurers
Private insurers accept premiums from individuals, businesses, and the government. In turn, they reimburse providers for taking care of patients with private insurance.
Health service providers
Providers (doctors, allied health professionals, hospitals, and other health care facilities) take care of individuals. They are reimbursed for their services by private insurers and the government. In 2002, government expenditures accounted for 44.9% of healthcare costs in the United States, and private expenditures accounted for the remaining 55.1%. The U.S. spent $1.7 trillion on health care expenditures in 2003. Of the $1.7 trillion used on health care, the majority went to hospital care and physician/clinical services.
Fee-for-service reimbursement involves paying the physician for each service (office visit, consultation, etc.), procedure (EKG, CT, X-ray, etc.), or
supply (cast, immunization, IV, etc.) provided. This is the only payment method in which every component of health care is reimbursed separately. Patients utilizing fee-for-service are typically enrolled in a traditional “indemnity” insurance plan, generally through private insurance companies such as Prudential and Blue Cross/Blue Shield. In indemnity insurance, the patient is reimbursed for medical expenses regardless of who provides the services. Reimbursement under
indemnity insurance involves three transactions: the patient pays the provider,the patient pays a premium to insurance companies, and insurance companies
reimburse patients for the cost of paying the provider (although the amount of reimbursement varies depending upon the plan). In an alternative method of fee-
for-service reimbursement, the physician submits a claim to the insurance company on behalf of the patient and then bills the patient for the remaining
balance.
User Fees
48% of Americans covered by private employer-based insurance obtain coverage through preferred-provider organizations (PPO's), which typically offer
incentives to enrollees to choose certain contracted providers in the form of lower coinsurance rates. 23% of those covered by employer-based health insurance are enrolled in health maintenance organizations (HMO's), which subject enrollees to monthly premiums and co-payments (average $10) when they visit their physician. 22% are covered by point-of-service/indemnity plans that allow free choice of providers, although choosing contracted providers is usually
rewarded in the form of more extensive benefit coverage. Finally, 7% have traditional fee-for-service plans that require enrollees to pay a monthly premium
(often with employer contributions). Their insurance company then pays providers for services rendered each month. These plans, however, often have
deductibles ranging from $250-500 as well as co-insurance requirements.
Reimbursement
Reimbursement within the US healthcare system occurs via several different mechanisms: fee-for-service, capitation, and prospective payment. Indemnity
plans tend to favor fee-for-service remuneration, while managed care plans often rely on capitation. Prospective payment mechanisms are also favored by health maintenance organizations.
Quality of Benefits, Choice, and Access
Medicare Part A provides for limited hospitalization and home health costs for all Medicare enrollees who have made payroll contributions throughout their lifetime;
Medicare Part B, on the other hand, offers a more generous benefits package extending to certain outpatient services and medical equipment. Medicaid
enrollee benefits vary by state, but the federal government mandates that certain medical services be covered, with other services (such as dental services) left to the state’s discretion. In the US, there are large disparities in healthcare according to gender, race, age, region, education, and socioeconomic status. For
example, despite possessing a large number of physicians (particularly specialists), 46 million Americans resided in areas experiencing primary
healthcare professional shortages in 2000. As another example, uninsured individuals are more likely than insured individuals to experience difficulty
accessing care and also tend to have worse health outcomes; indeed, the Institute of Medicine estimated that there are 18,000 preventable deaths a year
related to a lack of health insurance coverage.
Even with these barriers to access, US patients are generally informed,savvy consumers of healthcare in comparison to many of their European
counterparts. Particularly in today’s Information Age, patients are finding a wealth of information at their fingertips. Conversely, the increasingly specialized medical profession is struggling to stay up-to-date with recent developments; thus,physicians rarely possess more than a topical knowledge of areas outside of their specialty, which serves to level the playing field between doctors and the information-armed patients and to promote mutual participation in the decision-
making process.
The French healthcare system is primarily financed through general taxation and a payroll tax. Supplementary insurance and out-of-pocket payments
also account for a small portion of health expenditures. There are three main categories of earmarked national taxes for France’s healthcare system. First,
there are general social contribution funds drawn from a tax of 5.25% on total income (3.95% for the unemployed and social security beneficiaries). Second,
there is a tax levied on pharmaceutical companies. Finally, there is a tax on tobacco and alcohol.
The social health insurance contributions from employers and employees
(payroll tax) are set to be proportional for salaried employees and regressive for farmers and the self-employed. For salaried employees, employers contribute
12.80% of employee salary, and employees contribute 0.75% of their salary for such payroll taxes. In contrast, the contribution rate ranges from 5.90% to 6.50% for the self-employed and 8.13% for farmers. These contribution rates apply only for the first EUR 164000 of income; income above this level is not taxed
(Sandier, et al. 2002).
User Fees
Out-of-pocket expenses play a small role in France’s healthcare financing.
User fees via co-payments vary depending on the health service. Generally, French individuals are responsible for 30% of the cost of GP and specialist visits
(EUR 18.50 and 22.87, respectively), an average of 35% of drug costs (0% coinsurance rate for “effective drugs” and 65% rate for drugs with questionable
effectiveness), 40% for lab tests, and 20% for non-maternity hospital care during the first month (up to EUR 200). It is important to note, though, that French
residents can apply for co-payment exemptions for catastrophic health incidents resulting in treatment costing over EUR 200 (in 2000). Patients also pay extra
fees to see private practitioners. Many of the above costs, however, can be reimbursed through complementary VHI, which is purchased through one’s
employer or on an individual basis (Sandier, et al. 2002).
Reimbursement
The majority of physicians and specialists are paid on a fee-for-service basis (with the exception of salaried public hospital doctors), but reimbursement
rates vary according to whether a doctor participates in 'Sector I' or 'Sector II' Sector I physicians are paid according to the national fee schedule, and in
exchange, they themselves are guaranteed government benefits including free health coverage. Physicians who opt for Sector II can charge prices above the
national fee schedule, but they forsake the government benefits their Sector I counterparts enjoy. In 1997, only 27% of physicians practiced in the closely
regulated Sector II (Costich 2002).
Public hospitals and private not-for-profit hospitals operate via a global budget set by the regional hospital agency. Private for-profit hospitals have an
itemized billing system including a per diem charge for accommodations/care, a per diem charge for drugs, and payment for the use of operating rooms,
prosthetics, and other equipment (Sandier, et al. 2002).
Quality of Benefits, Choice, and Access
France’s healthcare system offers a wide range of benefits. Generally, medical services in the fee-for-service sector will be covered by insurance if they
are prescribed by a healthcare professional and are on the lists of approved procedures or drugs/medical devices (list inclusion is determined by level of effectiveness) (Costich 2002).
French residents are free to visit their GP, specialist, and hospital of choice without referrals, and they usually are able to make a same-day appointment to
see their GP. Access to healthcare is particularly good for school-aged children, as nurses and physicians regularly visit France’s public schools. The general
population’s experience with equitable access, however, has been more uneven.
27% of French physicians charge above the national fee schedule (Sector II),creating a barrier to access for low-income populations (Costich 2002). Moreover,
the waiting lists for surgeries found in other government supported healthcare systems do not exist in France.
After the research made on exploration of two health care systems in the US and France I consider that in spite of that the US government spends about $372.1 billion on Medicare there are some issues which can be changed. As it was mentioned before there are a lot of American citizens who do not have any insurance plan. Employers in the US provide health insurance for their employees, but usually it does not cover all expense or it is too expensive to have such full-service plan. Government also provides health insurance plans for people whose income is below a certain amount and people who overcome that amount are no longer qualified, but at the same time a vast number of people themselves are not able to afford the other health plan due to a low salary. Unlike the US France provides free health care or reimbursement for about 96% of population.
Most of common visits to doctor in France are free and the waiting time is very low, unlike the US. People in France have more health care benefits than people in the US; in order to afford more benefits for its citizens the US government will have to decrease government spending in other spheres such as defense or social security or increase taxes what in its turn will negatively reflect on people’s lives, their wealth, and health.
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Hohman, Jessica A. International Healthcare systems Primer. Ed. Kao-Ping Chua. 2006.
Ruth, Erin. Health Care Financing and Reimbur****t. Ed. Kao-Ping Chua. 2006.
Sandier, Simone, Valerie Paris, and Dominque Polton. Health Care Systems. Eds. Sarah
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