Health care reform controversy in both Europe and the United States

On my way onto the plane for my recent flight home from France I picked up a copy of Le Figaro thinking I might enjoy the article about actress Sophie Marceau, who was on the cover of everything while we were in France in celebration of her turning 40.

I did enjoy catching up on Marceau – I still remembering watching La Boum in my high school French class – but I couldn’t help but notice a two-page spread showing a large group of physicians in their white coats standing on the staircase at the Université Paris Descartes – a staircase I remember descending last year after my visit to the Musée d’Histoire de la Médecine.

It was the central image for an article about physicians writing a letter of protest to Sarkozy regarding French health minister Roselyne Bachelot’s healthcare reform bill. Whether it’s in the U.S. or Europe, it seems, health care reform must provoke controversy.

The article discussed the doctors’ objections to the allocation of decision-making power exclusively to hospital chief administrators (CEO’s / CFO’s), to cuts in staffing and services, and to decisions about patient care being made based on financial rather than medical criteria. Their battle cry, “Let’s Save The Public Hospital,” pointed to the increased economic burden that the current bill implied for teaching hospitals carrying the brunt of high-acuity, high-volume patient care.

Physicians weren’t the only professionals openly protesting Bachelot’s bill. Nurse anesthetists blocked train tracks at the Gare Montparnasse last May to protest the bill’s failure to recognize their specialty (France currently has 7500 nurse anesthetists).

Though I am much less familiar with the French system than the American, the article made me think about how my life might be quite different, both as a physician and as a patient, if I were living in France, as I have often fantasized.

If I were a physician in France I’d be making less. Primary care physicians in France get $32 for consultation ($37 if it’s a house call), whereas Americans under Medicare get $92 for the first visit and $125 for a “moderately complex consultation.” French Anesthesiologists make from 4000-7000 euros a month, according to one website.

But …

As a physician in France I wouldn’t have crippling student loans to pay back (the government would have paid for my education), and my malpractice costs would be significantly lower. I’d also be able to make decisions as I please without being muzzled by an insurance company – though as an anesthesiologist in the U.S. I can already do that; it’s usually primary care physicians in American who have to deal with the frustrations of having to adjust medical decisions based on insurance company restrictions.

In France I would, however, have had to have been in a science / medical track for most of my scholastic career, starting in high school, and would probably never have been able to do what I did in the U.S. – major in literature, then switch to medicine after university. I’d have had to do a lot of demanding oral exams – not just the few I got through here in the States. I’d have had my exam results posted publicly and my class rank determine my specialty choice (which does occur to some degree in the U.S., but less stringently).

As a patient in France, I’d be entitled to health care, but I’d perhaps be paying higher taxes, waiting longer to see specialists, and maybe even having to travel out of my home area for access to certain services, such as a labor and delivery ward. In either country, the system is tiered, with people able to pay for additional private insurance getting access to more services.

I don’t think there’s any perfect training system, practice situation, or place to be a patient, but as both a physician and a patient I’d probably want for myself the flexibility of an American education system coupled with the universal access enjoyed by the French. I dream of living in some idyllic little French village without worrying about whether I can get care when I need it; then I watch shows like BostonMed, and the familiarity of the American system wins me over all over again.

The problem neither country seems to be able to solve is the high cost of universal health care; Assurance Maladie, the French state health insurer, has been “in the red” for decades. I’m interested in seeing what both countries come up with in the coming years.

Anesthesioboist T is an anesthesiologist who blogs at Notes of an Anesthesioboist.

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  • Max

    Interesting read. What is the lifestyle like for physicians in France. For instance, what kind of hours do anesthesiologists work? Do they take summers off like most of the population seems to do? Vacation? Weekly hours?

  • Dr Lemmon

    The illusion that more government control or oversight will make health care better and cheaper at the same time. Don’t forget more access too. Things will be different, no doubt. But better. Who knows? A professor of mine in med school when speaking about universal government run health care said “cost, quality, access, pick any two.”

    Does not the fact that we were promised all three seem too good to be true?

  • no

    The decrease in total net worth due to the US medical school loans is overblown; its not nearly as big of a deal as people make it out to be. Most will dedicate about 30-40,000 gross annually for 20 years to pay it off. That is chump change (relative) for a physician making 200,000+ gross a year. I know EM, anesthesiology, orthopedic surgery, radiology, etc are still doing relatively well.

    If you want primary care then the military scholarships (HPSP, FAP) are actually solid choices financially.

    Yes, the loan debt is an important issue but most definitely not crippling.

    I’m a med student so I know what I am talking about.

    • family doc

      dear mr no,

      i completely disagree. i am a primary care doc. about 9% of my TAKE HOME salary GOES towards my student loans. this is not chump change. when you are out practicing, i think you will agree. and 30 to 40 grand is 15-20% of your gross salary paid to student loans. not chump change.

      and making 200 grand a year- certainly not in primary care. i agree that military scholorships might help financially, but what about the cost to your self, your family, your time NOT being a physician- specifically when you are deployed to iraq or elsewhere? what is the cost to living in some far-away base in the middle of nowhere of middle of america. all my friends who sighed up for the military in med school REGRET REGRET that decisionn now.

      when you are older, trying to buy a house (or save for the downpayment), fund your retirement you might disagree with what your saying in your post. if you are in one of the lower paying specialities, that 10% ( to 20%) really hurts in achieving your goals of becoming financially stable and preparing for your retirement.

      i know. when i was in med school i believed and said what you wrote above in your post too.

      how wrong i was.

      truly best to you in your endeavors.

  • http://www.twitter.com/alicearobertson Alice Robertson

    Anyone with romantic notions about not just living in France (the mystique of Hemingway and the ambiance is nice for the healthy romantic), but who defends or recommends the healthcare should fly there and throw themselves down a flight of stairs with their cell phone at the bottom so they can call for help (or just call then throw yourself down…you should have plenty of time). They will be on the next plane outta there…….as soon as their legs work. Reality and Romanticism upon confrontation usually means the romantic dies……and, hopefully, without permanent disabilities! But ya’ got me there….socialized countries often over some great government benefits.

    • http://anesthesioboist.blogspot.com T.

      You seem to be assuming that any “notions” about living in France must be “romantic” simply because France is often romanticized. There are actually some notions, however, that are based on the experience of being part of a French family that has had experience with both systems.

      Not sure if you were suggesting, too, that France is a “socialized country” but last I checked it was a republic with a capitalist economic system. It does, as you mention, offer some great government benefits – perhaps at the cost of a little disincentivization.

      Finally, there must be SOME reason that on the WHO’s ranking of world health systems, France ranks #1 and the mighty U.S. a paltry #37. I don’t pretend to have any expertise on why that is; all I was doing in this post, really, was wondering to myself what I would miss/not miss or like/dislike in either system, not defending one or the other as “the right way.” You must have had a really bad experience somewhere outside of the U.S. to make you suggest violent self-injury in order to prove a point. What happened?

      • http://www.twitter.com/alicearobertson Alice Robertson

        Facetious alert! I love facetiousness and regular posters know that. There is an article at the National Review that goes into how these stats are arrived at. Whether you like National Review or not it’s worth reading. I was trying to make a dramatic point…you know like a child that throws their body on the floor screaming. Maybe that’s how I feel about all this romanticized European medicine is the answer mantras. Sure we can learn from other systems (even Canada has specialists that specialize and do only one type of operation and have easier ways to become surgeons than the American system (Dr. Atul Gawande discusses this in his books, or maybe in The New Yorker?), but I don’t want Canadian medicine duplicated here. Yes, some aspects, but not the system.

        I simply don’t believe that France is number one. If it was rich Americans would be flying there. Oh yes, I lived in the UK…….yep………terrible experience, and most of my relatives are still being experimented on there.

  • F. Castle

    We, who are authentically attached to reality, repeatedly told the naive and clueless that the clueless T.R. Reid was WRONG about comparing USA healthcare to Taiwan and Europe.

    Well, we were right, and Reid made $$$. He’s so lucky — he’ll need the $$$ to fix the mess he help make.

    Nov. 2, this Obama-mess gets cleaned up.

  • jenga

    You are a med student, so by definition you don’t know what you are talking about. You are not a physician. You aren’t in practice. You haven’t received a letter from Sallie Mae yet.

  • http://wellescent.com/health_blog Wellescent Health Blog

    Commentary that criticizes the socialized health care of other countries really needs to be made on the basis of having lived in these countries and experienced how well their health systems work or do not work. A criticism based only on these systems being socialized is dismissive. With most of the health care systems in the world being socialized to some level, many of them equivalent or better than the US system, one has to ask themselves why such systems continue to thrive if they are so “ineffective”.

    • http://www.twitter.com/alicearobertson Alice Robertson

      By your definition I qualify, but that’s like saying I need to be a drug addict to know what it’s like. Experience is great, but it doesn’t trumph hard evidence.

  • Donald Green MD

    If the medical student feels confident he can pay back his loans and has developed a game plan to enter whichever speciality he chooses, why all the vitriol and discouragement? It is refreshing to see young students be positive about their future. The issue is not what care we deliver and by whom, which is excellent, but how people can reasonably pay for the care they deserve as citizens. It is under-insurance and no insurance that is dangerous to a person’s health and economic well being, not the services available.

    So “no” turn off the sourpusses here who are dealing with changes they haven’t developed the coping skills for. I wish you luck. You have the back of a solo family doctor retired in 2007 after 35 years in practice and who developed the foresight to understand that some planning and thought is necessary to be successful in practice. Carping and insisting on having it your way is what truly makes dinosaurs.

  • http://www.twitter.com/alicearobertson Alice Robertson

    Identifying the problem is a good beginning, but what happens when the government gets involved is a ton of people get knee-capped to help a smaller minority. How is that fair? There are better answers, and I have said this before on this board. The people who truly can’t afford insurance could have been placed on Kaiser for one-tenth of the cost of this current bill, that will surely hurt the majority of us in some manner. To say we are balking because it’s not implemented yet, is not a very good rant, because doctors are supposed to practice preventative medicine and prevent problems. And, of course, there will be some good aspects, every bill starts out lofty, then pork, and all this supposed merit that is going to help the political moi’s!

    The problem is when I post this stuff I get rebuked for not caring for the uninsured, and that’s far from the truth. It’s one thing to want to help the uninsured, but it’s another thing to have the government regulate to the point the public feels as if they have no say, and the majority do not want this bill the way it is.

    • Donald Green MD

      Very interesting. How did you get “knee capped” to help a smaller minority.

      Kaiser premiums are not cheap either.

      This bill covers more people under Medicaid and sets a floor for reasonable coverage.

      What it leaves untouched is insurance companies ability to raise premiums. This will have to be chapter 2 of this law.

      I do suspect you do have a slight tinge of resentment that you might have to help the uninsured: “but it’s another thing to have the government regulate to the point the public feels as if they have no say, and the majority do not want this bill the way it is.” The latter is usually in small print and conflicts with the first part of your statement. It is not logical. This bill was passed by your representatives not some imposed dictum.

      • http://www.twitter.com/alicearobertson Alice

        I do suspect you do have a slight tinge of resentment that you might have to help the uninsured[end quote]

        Resentment? Hmm………I volunteer with the needy for free! Do you mind if I ask you when was the last time you risked your life to go into the deep ghetto to help others? Or what percentage of the uninsured your practice handles for absolutely nothing…..I mean it’s clear you are filled with such compassion for the uninsured I am just assuming you work at a free clinic? I hope so……it would be consistent with your train of thought.

        Kaiser is a fantastic option that would have left our insurance alone. Cleveland Clinic had some nice proposals that would have come in far cheaper, but I guess it didn’t feed our representatives at the proper trough. I have a child with cancer, so I have a horse in the race……so, yes, it’s of concern to me what the end result of all this legislation will do (and that’s a blanket statement because I have libertarian leanings, while not being a libertarian).

        What bothers me the most about liberals ( I don’t know you, so I am not finger pointing at you specifically…just speaking generically from experience in past conversations here that go nowhere because they label you and don’t even try to find the truth. Opinions are fine when they are based on reality) is they refuse to see the end result.

        Knee-capping……, indeed, the way we are traveling in this current bill (which I hope can be repealed….because over 2,000 pages is outrageous and can’t truly be implemented fairly when the people who voted it in don’t know the details). If the extremists are right we are in big trouble in the future. But reality beats believing in a fairy tale. Not everything that glitters is gold.

      • http://www.twitter.com/alicearobertson Alice

        This bill was passed by your representatives not some imposed dictum. [end quote]

        Did you see the lastest Rasmussen poll? The majority wants new representatives, and the majority of the country want the health care bill repealed. So, you really think our legislators are reflecting the will of their constituents or themselves? There is information on CNN about this too….if you don’t like Rasmussen.

        Surely, you aren’t saying that a minority of needs outweighs the will of the actual people? We can get into wrong or right and the relativeness of that later if you choose. I am just stating facts because we can argue all year about the morality of whether it’s a privilege or a right to health care.

        62% Say Country Better Off If Most Members of Congress Defeated This November – August 23, 2010

        http://www.rasmussenreports.com/public_content/most_recent_videos/2010_08/62_say_country_better_off_if_most_members_of_congress_defeated_this_november

        • Alina

          The bill was passed by the insurance companies really and they get to cry about it over and over so we think that they also got the short end of the stick. Please, give us a break with this non-sense.

  • Jenga

    That is exactly what I’m saying. I have no idea what being a drug addict is like. Do you? I would value someone’s opinion that has experienced it over someone who “thinks” they know what it’s like.

    • http://www.twitter.com/alicearobertson Alice

      Well, of course I do! I was a prostitute, junkie in a past life! ha! I just had a talk with my inner-self. What do you want to know about selling your body for drugs?

  • no

    To: family doc and jenga

    Absolutely incorrect. The numbers don’t lie. Yes, 30-40,000 gross a year for 20 years is a great deal of money. However, if you are pulling in 250-300K gross annually, it is NOT a major inconvenience. If you can’t live on 200,000 gross a year to fund retirement, you’ve got problems in managing money. In addition, the ~34,000 gross that I dedicate annually to my loan debt will be worth less and less with each passing year. The absolute amount is stagnant but the real value is ever decreasing.

    Not everybody has to do primary care. According to the NRMP data, specialties such as anesthesiology and EM require average USMLE step 1 scores. Thus, if I am an average student, (and have some research, solid grades, etc) I should be able to obtain those residencies.

    The fact that I am a medical student does not preclude me from making intelligent, objective analysis of the financial situations that doctors face. Many medical students and residents have no clue about personal finance; being a doctor does not make you proficient in those areas.

    I see a lot of health care professionals (relatively highly paid, 200K+) making idiotic financial decisions and spending way too much money. No, medicine is not great for being incredibly rich (10+ million annually, etc) but if one is frugal it can yield a very comfortable nest egg.

  • no

    To: family doc and jenga

    In regards to whether medicine is “worth it” financially as a career, that is up in the air. (considering the time investment and residency) The opportunity cost, loan debt, and personal sacrifice are heavy, to be sure. Personally, it may or may not be financially satisfying depending on residency. I haven’t done 30 hour shifts yet (well, I believe the upcoming caps are 26 hours or so) so my stance may change on the topic.

    Thankfully, my materialistic “needs” are VERY low so I will be financially independent. I recall a conversation that I had with a relative (non physician) that said, “When you become a doctor, you’ll want the nice car and house.” My reply: “Nah, not really.” As long as I have my health (physical, mental, psychological) then I will be relatively content. The best things in life are free. :)

  • http://www.twitter.com/alicearobertson Alice

    The best things in life are free. :) [end quote]

    Yes, it’s all wallpaper on life! How great you aren’t seduced by the allure of that which is over-and-above our basic needs. I had that attitude and decided to let God decide how many children I have, instead of me and my finite mind…..I have six (I was terrified…now exceedingly grateful and wish I had more, and don’t have a lot of use for materialism…..not that I don’t own a car….I am not ready to cast it all away and live in a cave yet).

    I really hate when a conversation denigrates to the point of experience only. Sure experience counts, but sometimes it’s like saying I have to jump off a cliff ,and then live to tell, in order to have a voice. Sure, my voice may be limited by my inexperience, but to say someone has to have lived somewhere, or lived a certain lifestyle, to have a voice is just plain silly. What’s really silly about it is if a doctor says it…….the logic is so lacking……because a doctor treats diseases they will (hopefully) never experience firsthand, yet they are competent. That said I wasn’t too keen on residents getting their experience on my child (and sure enough one of them caused some real trauma that was unnecessary). And by the same token maybe we shouldn’t discuss retirement until we have retired, we shouldn’t talk about raising children until our kids are raised, etc. etc. Do we have to experience medical negligence to know we don’t want to be on the receiving end of that? Limited though a voice may be, if it’s studied or inquizzative, we should listen.

    • Alina

      “I really hate when a conversation denigrates to the point of experience only. Sure experience counts, but sometimes it’s like saying I have to jump off a cliff ,and then live to tell, in order to have a voice.”

      Alice – you hate it because people call you on the things you post. You don’t have to jump off a cliff, you just need to refrain playing the expert on things that clearly you have no knowledge of. By your continuous posts on several articles regarding the wonderful “free market” insurance-based model, it’s clear that you have some stake in all of this. You denigrate the healthcare systems in the European countries one by one: started with UK when you told us you lived there, then you said you didn’t, now again you’re saying you did. You posted a “reliable” source which outlined how horrible that system was. Yet the Times had an article about the UK system just last year and it was quite complimentary. You said that one of relatives was denied antiemetics medication by the NHS. What medication is that? The NHS posts not only that they cover these type of medication, but that is also free for cancer patients.

      Then you went on to Germany, then Russia, and now France. It’s all a big socialist conspiracy to you, yet you never lived in a socialist society and you don’t have the slightest idea what that means. So what makes you an expert in such matters?

      I replied to you at a different post and presented some stats from the Kaiser Family Foundation which is a reliable source. It seems that in your opinion, not only one’s experience should not count, but same should go for any shred of evidence. In your mind everyone is wrong. Well, of course…except the insurance companies. I asked before what is the purpose of these companies? They are nothing more than oversized leeches that suck us dry by taking in billions (with a B) of dollars in profits every quarter for doing absolutely nothing.

      Incidentally I came across an article earlier today which outlined some US stats. Here are the sources:

      1) Number of underinsured people – 25 million in 2007 alone.

      http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2008/Jun/How-Many-Are-Underinsured–Trends-Among-U-S–Adults–2003-and-2007.aspx

      2) In addition 72 million reported problems with medical costs, while 80 million reported not accessing prescribed medication due to costs (copays, coinsurance, etc)

      3) Underinsured tend to have high deductible plans, annual maximum limits and a variety of other limitations

      http://energycommerce.house.gov/Press_111/20091015/collins_testimony.pdf

      4) Since you talked about oncology treatment in the UK, here is some new data regarding treatment availability for the US patients (I posted additional data for you at a different article):

      Gleason PP, et al. Oral Oncology Prescription Abandonment Association with High Out-of-Pocket Member Expense. J Manag Care Pharm 2010;16:161-162

      ……and the list goes on.

      It’s great to have a debate but you need to use real and unbiased information. Otherwise you have no credibility, so stop complaining.

  • http://www.twitter.com/alicearobertson Alice Robertson

    I am clearly no expert on the French. Just some questions though. Is it true the average French worker has to donate 21% of their salary to pay for their healthcare, then they have out–of-pocket expenses (with employers covering the other half of the bill to the government, which means jobs are affected by this because employers view potential employees as not just a service, but another tax burden)? Isn’t the French government in debt to the tune of billions for healthcare? Which means the people are paying more-and-more? Isn’t it government run health care? Is it a singler-payer system?

    Don’t the French have less obesity and healthier lifestyles than Americans? Is it their system or lifestyle that helps the French?

  • jenga

    Alice.
    Anyone can have a voice. It’s my choice to determine whether I think it’s worthwhile and will take credence with it or not. No was talking about how easy is to pay back student loans when he or she hasn’t spent a dime paying their’s back yet. Sorry, I think that is laughable and I don’t find it very credible, my perogative. It’s analgous to that are eager to tout the virtues of war, when they have never served, been shot at or won’t have their loved one’s in harm’s way. Such a line of thinking is completely logical. If you have never lived in a place and have a strong opinion about it. Can’t say I’d take alot of stock in that. If a physician experiences a disease, they very well may be more competent that a physician that hasn’t. I don’t know why you would deny that it could make them better. That is completely logical. Some of the best sports medicine physicians have torn their own ACL. OBGyn’s that have given birth themselves and so on. Etc I wouldn’t trust a book about raising children, written by someone without children. Would You? Medical negligence, no one wants to be in pain or injured. Everyone has experienced that.

  • http://www.twitter.com/alicearobertson Alice

    Medical negligence, no one wants to be in pain or injured. Everyone has experienced that [end quote]

    But that only makes you an expert on fear, not the negligence. My daughter was personally injured by a specialist, so I guess I can trump anyone and be the leading expert on that? I have raised children, so I am now the expert on that too! :) Oh yes, two kids with cancer, so maybe I am now world-renown……..ha!

    Are you sure you don’t want to pick my brain about my prior lives? Some pretty interesting characters lurking in there with first-hand experiences……..going once…….going twice…..:)

  • PAULMD

    no,
    “grow up, learn something”
    Lana
    Risky Business

    When you see the money that is changing hands and those making money on the sweat of your efforts (insurance companies, Pharma, military medical industrial complex) you will be angry, repulsed and change your tune. When someone mandates you volunteer your service, it’s not charity.

    If and when no one is making a pound of flesh off of your effort and you do it of your own free will, that is charity and it feels pretty good. We will be getting the latter (no money) but also the former (you will provide)…and that is slavery.

    Get back to us in a few years.

    • Alina

      Paul,

      Some of you guys always complain about how little money you’re making. Would you care to let us know what exactly you consider little or “no money”
      How much money would you consider sufficient and for how long?

  • http://www.twitter.com/alicearobertson Alice

    We will be getting the latter (no money) but also the former (you will provide)…and that is slavery. [end quote]

    Must be who you are working for. Is it yourself? My doctors seem really happy where they work, and they are living well too.

    They are in the same occupation as you, dealing with the same regulations, insurance companies, student debt…….what is the difference that they seem to think being a doctor was worth it?

  • PAULMD

    Most of us see the storm clouds coming Alice.
    “One of these days Alice…one of these days….”
    Ralph Cramden

    • http://www.twitter.com/alicearobertson Alice

      LOL. Now that was a really good comeback! Um…..yes…..I agree…..but I can’t belt out the refrain from Stormy Weather!

  • jenga

    No, because I don’t need to know about such things, thankfully. If you don’t think you have something to offer such as insight about raising kids, them getting sick with cancer or your experience about what you thought was medical negligence, then I can’t help you. I think you would instantly have something to add over someone that hasn’t experienced any of those things. I know it’s shocking people might ask you for advice. It might be worthwhile.

    • http://www.twitter.com/alicearobertson Alice Robertson

      Jenga that was a very nice response. Sincerely, I mean that. And as you can see I could really use a friend right now! I’m tellin’ ya’ I need a cyber-shoulder to cry on. Where is Paul when you need him to cheer you up? :)

      By-the-way my jokes about inner beings is because I come here and talk to people who I have no way of knowing who they are. I just answered another poster and for all I know I could be talking to a prisoner or exchanging recipes and health tips with Hannibal Lecter.

  • PAUL MD

    to Alice,
    As myopic, scared and arrogant as I can be I cannot even remotely fathom the depths of your pain regarding your childrens’ illnesses. I have a five and seven year old and they are the greatest gifts that my wife and I have ever and will ever give ourselves and their value in our eyes is limitless.

    I seem to have no original quipey thoughts and sit here stealing lines from old movies to do my bidding. Pathetic if you ask me. If they bring a smile to you then all I can say is, “you had me at ‘hello’”.

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