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8/8/2019 Comparison of Health Care in the US and Europe
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National HealthcareA comparison of the French and United StatesInsurance Policies
Peter Gates
12/10/2008
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Sc4s2cgPeter Gates
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MWF 8:45am class
1
A Comparison of the United States and French Healthcare Insurance Policies
It has come to the attention of the American public in recent times that the United State
healthcare system is in crisis, and the people are ready toaccomplish something about it. According to
one Gallup poll, support for maintaining the current healthcare system has declined dramatically from
61% in 2002 to an astonishing, below-majority level 41% in 2008. Furthermore, 77% say that the current
healthcare system has either major problems or is in a state of crisis, an increase of almost 10%
since 2000, while just 25% state the other extreme thatthe system has either minor or no problems
at all. Americans perceptions on the quality, coverage and costs of healthcare have been asked as well,
with the results indicating that 55% view the quality as good or excellent, 72% the coverage as being
only fair or poor, and 81% showing dissatisfaction with the total costs of healthcare. Interestingly,
despite the pessimistic views of healthcare overall, 70% viewed their own coverage as being excellent
or good with only 23% stating that it isfair or poor. The conclusion can safely be made that
Americans are concerned about healthcare out there, but are rather comfortable with their own
coverage. In support of such a conclusion, 57% are satisfied with what they personal ly pay for
healthcare while 39% are not, in contrast to the previous statistic that states that 81% are dissatisfied
with the costs of healthcare overall.
A comparison with the French view shows a slight difference between the confidence of the
citizens of France and the United States in their own healthcare systems; 82% of the French and 69% of
the United States are confident in their respective medical systems. However, when the question
changed to whether or not the respondents felt they could pay for their medical costs, 12% of those in
France and 32% of those in the United States expressed concern at having not enough fundsin order to
cover all costs. These facts are further reflected when the CIA World Factbook stated in 2008 that
citizens of France are living, on average, three years longer than those in the United States, 81 and 78
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years respectively. Moreover, the Factbook states that infant mortality rates in the United States, being
three deaths per 1000 births, are almost twice as much as that in France, approximately six deaths per
1000 births. Statistics such as these clearly show a need for change in the United States health system
and the people are more willing than ever before to show support for such arenovation. In order to
help the reader to decide whether such a transformation is possible, or indeed advisable, this papers
primary focus will be on the difference between theways insurance is dealt with in the two nations. The
first portion will deal witha short history of insurance in both countries and will then go on to describe
the different types of insurance available and state various appropriate facts that will undoubtedly
conclude with the opinion that it is advisable for the United States to adopt a similar program to that of
the National Health Insurance (NHI) provided by the French government.
Introduction
Considering the history of the United States, the debate on national health care should not be a
surprise. It is just natural for the nation that has been founded on the basic principle of unalienable
rights to question what those rights are. As a nation, the United States has decided that allpersons,
regardless of their skin color, country of origin, gender or religious status, areequal in the eyes of the
law. That all persons have the right to their pursuit of happiness, whatever that happiness might be,
without the interference of the government. In light of these historic moments, one will easily
understand the importance of the current debate on healthcare. In some ways it is similar to the past
debate on _____________; both raised the issue of competition and government rule, as well as costs
and morals. Both have been brought to the attention of politicians, including presidential candidates in
the presidential debates, and both have had congressmen trying to pass bills one way or another. And
because this debate on the universal coverage of healthcare will affect every American in the nation, the
primary focus of this paper is to compare, contrast and draw conclusions between the United States
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current health care system, and Frances universal health care system, rated by the World Health
Organizations as number one in a worldwide study of healthcare.
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nt [A3]: Add that comma in?
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The United States
The key focal points for the healthcare in the United States are, as in most other
countries of the world, the hospitals, clinics, retirement centers and various other institutions related to
the health of the individuals. The major institutions in the treating of sickness is, also as in other
countries, the hospital; as can beseen by the dramatic increase in infrastructure from 178 in 1873 to
6000 in 1946 (Young & Sultz, 1999). That number has been more or less kept the same since then, with
it peaking at around 7000 in 1980and then going back down to decline to around5000 in the 1990s
(Young & Sultz, 1999). After World War II, as technologies erupted in an exponential manner and as
hospitals started to become a key technological focal point in the field of medicine, the demand for
hospital services has increased exponentially, also fueled by the near nonexistent direct cost to the
patient as employers picked up the tab, to such an extent that in 1946 the Hi ll Burton Act, sponsored by
Senators Lister Hill and Harold Burton, was passed by Congress to provide federal moniesey to hospitals
for the purposes of expansion and construction. As a result, more than 4600 additional projects were
started to either expand upon or to construct brand new facilities over the next 20 years(Young & Sultz,
1999).
Added to this golden year for the American people, the Medicare and Medicaid actswere
passed in 1965 as a part of President Lyndon Johnsons Great Society plan, authorized by Titles XVIII
and XIX, respectively, of the Social Security Act as a way of helping the elderly and those in poverty pay
for necessary medical bills (Jonas, 2003). Medicare was constructed as a way of ensuring insurance for
all elderly persons; one does not need to apply or meet any points but is automatically enrolled.
Medicaid on the other hand differs from stateto state with persons seeking aid having to apply and
meet certain requirements as prescribed by the state government. Of the beneficiaries for Medicaid,
45% were children, 42% disabled persons, 29% aged adults and 19.5% non-aged adults (most of
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Comment [A4]: Change to: the health of the
individuals?
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C
nt [A5]: Institutions?
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C
nt [B6]: If you are talking about just
hospitals, I wouldnt say hospital infrastructure. bit redundant.
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C nt [P7]: Kind of went on a tangent. N
to further explain hospitals and make a new
paragraph for Medicaid/Medicare. Perhaps unde
financial section?
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C nt [A8]: Change to Medicaid, on the
other hand, differs from state (add commas)
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whomwhombeing mothers with covered children). Despite these statistics, 70% of all expenditures in
Medicaid went towards the benefits for the aged and the disabled(Jonas, 2003). However, with the
rising costs of technology during the 1970s an 1980s, it became apparent that something was needed to
be done for Medicare to continue; and so a system called diagnostic related groups (DRGs)was created
in 1983 by the federal government. In order to lower costs, the government would pay hospitals the
average cost of care for the patients particular disease or condition, regardless of the time spent in the
hospital. If patients stayed in longer than the average, hospitals would lose money, but if patients stayed
for a shorter amount of time than the average hospitals would gainrevenue; similarly, if patients stayed
the average time, it would be at no cost to the hospital(Young & Sultz, 1999). This approach to costs
was quickly adopted by all states and hospital insurance companies and has been expanded to include
patients outside of Medicare as well. Pretty soon, however, it became apparent that such an approach
would result in hospitals discharging patients at sometimes dangerously earlier times in order to gain
more revenue. Many times this policy did not affect patients as such, however other times such
practices led to a later return of the patient with a more serious, and thus more expensive, illness or
chronic disease, contributing to the rising costs of healthcare. (Young & Sultz, 1999)
The rising costs of healthcare due to technology has become apparent in the general sector as
well, not just in Medicare and Medicaid, as Congress found out in Peter Orszags 2008 testimony on the
rising costs of healthcare where many f igures and comparis ons were mentioned. The most striking,
however, is the fact that between 1965 and 2005 expenditures on healthcare has tripled every 20 years.
In 1965 expenditures were $187 billion dollars and 5% of the Gross Domestic Product (GDP) and in 1985
it has risen to $666 billion. The most recent figures, that of 2005, states that national expenditures on
healthcare is now $1.9 trillion dollars, or 15% of the GDP (Orszag, 2008); in other words, healthcare
expenditures can be looked at as 20% of the current United States national debt of $10 trillion as of this
writing, according to Ed Halls National Debt Clock. The reason for such spending has been identified by
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nt [A9]: What technology?
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nt [A10]: Change to was
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nt [A12]: Remove dash
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nt [B13]: I would phrase is sometim
discharging patients dangerously early.
dangerously earlier times just sounds awkward
me.
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C 6 7 7 8 nt [A14]: Change to Practices?
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C 9 @ @ A nt [A15]: Change to: Not just in
medicare and Medicaid.
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C B C C D nt [A16]: Insert comma between dol
and or, so it will be dollars, or 15%
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C E F F G nt [A17]: Put fullstop in place of
semicolon.
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C H I I P nt [A18]: I think its actually 19-20%
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Senator Orszag as being dependent on six key factors: the adoption and emergence of new medical
technologies and services, which contributed between 38-62% of total medical costs in 2000 as some
technologies may introduce newer categories of spending; the aging population,although it only
contributes 2% as the population ages rather slowly; the growth of personal income (11-22%), as people
gain more income the opportunities for health care willincrease with demand increasing as well; prices
in the health sector also contribute 11-22%; and finally administrative costs which account for 3-10% of
health care costs. Another key factor that was also identified was the obesity epidemic that the United
States faces today. As a person moves up on the scale from beingnormal weight to overweight,
obese, or morbidly obese, the per capita spending on him or her increases with an average of
around $1000 as he or she moves up the scale. When one considers that the populations overweight,
obese or morbidly obese persons has increased from 44.9% in 1987 when the populat ion wasaround
250 million, according to the Census Bureau,to 59.6% in 2001 when the population was just under 300
million, it is easy to see how significant this is in terms of the costs of health care. Added to this is the
fact that the obese category has seen the most increase,from 12.2% to 20.7% between 1987 and
2001, thus resulting in anincreasingly higher number of dollars being spent on that category. If current
trends continue without outside intervention, the expenditures on health careare projected to reach
100% of the GDP by 2082. Even with outside intervention, for example Congressional pressure or
consumer demand, expenditures are still projected to reach 50% of the GDP by 2082 (Orszag, 2008).
The increase in costs has happened despite certain changes to the healthcare systemunder the
default guise of Managed Care Organizations, or MCOs. MCOs Composing the MCOs are ordinarily an
insurance company and many hospitals, physicians, and beneficiaries. The purpose of these
organizations is to help lower the costs of hospitals and increase efficiency throughvarious means,
ranging from negotiations to limits on the use of certain services, and sometimes reaching the point
where the laying off of staff may be needed. There are sevenmajor Managed Care Organizations that
C Q R R S nt [A19]: Contributed to between?
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only contribute 2% as the
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contribute
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that was identified was the obesity epidemic
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Ci p p q
nt [A24]: Since normal is done in spe
marks, overweight should be too, as with obese
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Cr s s t
nt [A25]: Change to: when one
considers that the populations content of
overweight, obese or morbidly obese people
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C u v v w nt [B26]: In 1990, it was just under 2
million.
http://factfinder.census.gov/servlet/SAFFPopula
?_submenuId=population_0&_sse=on
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C x y y nt [A27]: Eek. Thats scary.
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ranging from
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are listed by Steven Jonas, the largest of these beinga group called the Health Maintenance Organization
(HMO) that not only insure groups of people, butprovides the medical services that are under the
insurance coverage. There are two models of the HMO; the staff model where the HMO runs the entire
operation, including employing physicians and paying the appropriate salaries, and the so called group
model, wheree physicians grouped together into separate self-governing multispecialty group services
who then contract with the HMO to provide medical services. The HMO will do everything else in terms
of insurance, salaries and so on, but the physicians are paid through their specific group througheither
aa capitation, fee-for-service, or salary basis.
The other six of the MCOs listed by Jonas include the Preferred Provider Organizations (PPOs)
which are a group of independent providers (private practitioners or medical groups) who contract with
an insurer to provide certain services for predetermined fees, usually for more serious care that does
not fall under the term common care. The fees are many times below the prevailing market rates.
Exclusive Provider Organizations (EPOs) are similar to the PPOs,PPOs; however instead of allowing
beneficiaries to choose whether or not to accept care f rom service providers, EPOs havehas a list from
which all members much choose from to receive any type of reimbursement for care. IPAs, or
Independent Practice Associations, are more closely related to HMOs financially, as they are a group
where physicians are allowed to stay in their own officesand must see only HMO enrollees.
Independent Practice Organizations (IPOs) are similar to theIPAs,IPAs; however physicians are
permitted to care for patients from different insurers other than those from just a particular HMO
company. Finally, the last types of MCOs are the Physician Hospital Organizations (PHOs) or the
Combined Provider Organizations (CPOs) which are a combination of the previous four organizational
types, except for the slight detail that it is organized by the hospital and its staff to allow the staff to
negotiate directly with patients by taking out the middle man, or in other words the PPOs, EPOs, IPAs
and IPOs.
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nt [A32]: Add comma model, wher
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they
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Despite the complexity apparent in this type of an insurance system, as of 2001, 71% of
Americans had some type of private health insurance(Jonas, 2003). The flip side of the issue however,
is the fact that although the majority of the population is covered by some sort of private insurance,
30% is not. That would constitute to being aroundThis figure translates into almost nine million
uninsured children and a further 33 million uninsured adults in the United States who cannot accept
healthcare charges without serious financial consequences.
France
It might come as a shock to the average United States citizen that France has a nationalized
healthcare that provides healthcare to most of its citizens nearly free of chargeThe French acceptance of
insuring every private citizen with governmental health insurance might come as a shock to many
Americans. In factIndeed, to repeal such a policy is an unthinkable move, akin to eliminating the fireor
and police departments in the United States. Healthcare in France is seen as a right of society that must
be provided by the government a concept which might prove to be easier to understand if one first
understands why the French citizen accepts such an unusual form of healthcare. Three basic principles
play a role in this French way of thought (Minogiannis, 2003): social sol idarity, healthcare as a public
good, and what is called La Mdecine liberale,or liberal medicine. Each of these principles are a key
factor in the French thought and what makes the French so resistant to any kind of drastic changesto
their current healthcare system. Social solidarity is the idea that social assistance provided by the
government is a necessary responsibility, not a shameful situation, if the country of France is to flourish
locally, nationally, and internationally. From this concept follows the idea that health care is a public
good, the logic of which is best described by Panos Minogiannis in his bookEuropean Integration and
Health Policywhen he stated, it follows naturally for [the French population] that the state as the
institutional personification of the nation will have to provide [healthcare], since public good cannot be
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Comment [B35]: You make this sound like th
current complex insurance system is doing a goo
job. Id rephrase this to emphasis that ONLY71%
people are covered, especially when compared t
the rest of the western world since your conclus
is we need a universal healthcare system.
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Comment [B36]: Repeal? Dismantle?
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Comment [B37]: You are basically repeating
what you just said in the last sentence here. I wo
rephrase to something like: Each of these tenet
play a significant role in why the French are
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Comment [B38]: They are open to reform, I a
sure, but they are opposed to drastic change. I
would use drastic change here.
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produced and allocated efficiently and equitably by the market (2007). The last French basic principle
of thought is the idea of La Mdecine liberale, liberal medicine, which in basic terms is a four-piece
doctrine that ensures the private practice of medicine in a way that guarantees: a patients freedom to
choose his or her physician, the physicians freedom to prescribe as per their best medical judgment, and
a fee-for-service type of payment which will be made directly by the patient to his or her physician after
the appropriate services have been completed.
Once an understanding of these French basic principles has been obtained, it is important to
have understanding grasp of the French healthcare system before the 2005 reforms prior to
discussinghowdiscussing how the French system is as it exists today (Wikelius, et al., 2008). As such, the
primary focus of the next section of this paper will be on the various ways that the French system was
organized preceding the reforms and will further conclude with the way it changed during the last three
years.
Unlike the United States healthcare system, which boasts numerous types of managed care
coverage under which fall various insurances, hospitals, physicians and organizations, the French
healthcare system still has but two types of coverage: that of the governmental general coverage
scheme, and a private supplemental coverage scheme (Minogiannis, 2003). These two schemes
covered nearly 100% of the population and accounted for various percentages of the overall healthcare
expenditures as expressed per the following: the general coverage scheme (Regime Generalor
Assurance Maladie) covered 74% of the total health expenditures, almost 90% of the total hospital
expenditures, where most services were performed, and 57% of the total ambulatory expenditures.
Supplemental coverage also covered these expenses, however not to the extent asRegime General. In
short, supplemental coverage covered 6%, 2.1% and 11% of the total health, hospital and ambulatory
expenditures respectively. To make up the rest of the 100% needed for total coverage of expenses, the
government chipped in 1% for the totalhealth costs, and the patients themselves paid out-of-pocket
C j j k nt [B39]: I would simplify this to just
has or still has.
C j j k nt [B40]: You said two types, but this
reads like three. I would say, the government w
a general coverage scheme and a private
supplemental coverage scheme. Or something
that.
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expenses to cover 19%, 7.5% and 32% of total health, hospital and ambulatory expenditures respectively
(Minogiannis, 2003). With France being named the fourth highest ranking country in terms of
expenditures on healthcare (Minogiannis, 2003), and the number one highest ranking country on the
quality, satisfaction, and reach of that healthcare by the World Health Organization, figures such as
these are very important. Especially so when taken intoaccount is the fact thatFrance has spent almost
$157 billion dollars on health care and devoted 10.2% of its Gross Domestic Product to providing quality
healthcare to all its citizens (Freeman, 2000).
As stated previously, the General Coverage Scheme of France, also called the National Health
Insurance (NHI), covers 74% of the total health care expenses. Before the 2005 reforms, three primary
funds were used to help the NHI cover the price tage of healthcare. The first of these funds, the general
sickness fund, covered 82% of the population and controlled the16 regional funds, that has the
responsibility of capital planning, and numerous local funds whose main responsibility is to oversee
[the] collection of contributions and the reimbursement of claims (Minogiannis, 2003). The second of
the funds, the agricultural fund, covered those in the agricultural sector and its dependents,and thus
nine percent of the population. Finally, the third major fund is for the self-employed and professionals
and their dependents that makes up 7% of the population. All together, these three funds covered 98 %
of the working population with a further 1.5% being covered by otherspecialized funds, and the
unemployed through social security. The general fund set up the basic model of how the required funds
were to be collected, with the other funds following that model, through a combination of employer and
employee taxes, with the employers picking up two-thirds and the employees one-third of the
premiums (Freeman, 2000). The unemployed under the care of social security had, and still has, their
premiums paid for a predetermined time after which, if still unemployed, they may get access to
sickness funds through special individual rates(Minogiannis, 2003). Before the reforms, around 0.5-
1% of the population, or 200 to 500 thousand people, were without insurance at any given time.
Cl m m n
nt [B41]: Already mentioned this last
sentence. Bit repetitive here.
Cl m m n
nt [B42]: Which accounts for?
Cl m m n
nt [B43]: Should this be under the c
of social security or am I missing something her
C l m m n nt [B44]: I know you are trying to ref
to pre- and post-reforms of 2005 with this
construction, but I am not a fan of it. I would usejust have or still have.
Cl m m n
nt [B45]: I like people here better.
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Although 98% of the population was covered through the NHI, a separate Supplemental
Coverage Scheme was in existence to not only envelop the other 2%, but to include issues not covered
by the General Sickness Scheme. Such issues include, in the words of Minogiannis, very serious and
catastrophic illnesses in the form of cancer, AIDS, or other chronic lifetime conditions. Furthermore,
the Supplemental Coverage includes a variety of luxuries, for example separate private hospital rooms,
and also co-payments that the population is expected to pay. These fees charged by physicians are
predetermined by a national committee comprised of all the three major funds and the three physician
unions, where annual negotiations take place on the amount to be charged. The agreed upon fees are to
be applied across the board and are required of each physician, including private physicians.Fees such
as the le ticket moderateurs (moderating tickets) were kept in order to avoid any moral hazard type
of behavior (Minogiannis, 2003), or in other words using the hospital facilities when such facilities were
not needed for such a light condition. About 88% of the population choose to carry supplemental
coverage, while those who do not are usually either financially unable to do so or else just simplydo not
consider themselves to be at risk for chronic conditions.
Reforms in 2005 made the practices that have been going on until thenofficial; namely that the
different funds were aligning themselves closer to the General Fund untilFrance had, in practice, a
single-payer system. In a sudden catch-up played by the government, practice has become theorywhen
the General Funds were renamed the National Union of Health Insurance Funds (UNCAM), and added
the responsibility of negotiating with health professionals regarding the modes of contract that may be
needed to regulate fees and medical practices, in association with supplementaryinsurers and other
professional associations. With UNCAM all General and specialized funds, such as the Agricultural Fund,
has been turned into one, effectively covering the entirety of the living population in the country
(Wikelius, et al., 2008). The coverage has not gone so far as to cover 100% of the costs, so many of the
so-called moderating tickets have been kept in place for less serious issues, as in the case of the dental
C o nt [B46]: Id consider rewording this
seems a bit clunky.
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coverage which covers 70% of the costs. However, more severe conditions require more serious
coverage, and thus 100% of irreplaceable and costly medications are covered under the reformed
health insurance (Wikelius, et al., 2008). Furthermore, in keeping with the concept of le ticket
moderateur, individuals receive one Euro less reimbursement (this fee is non-coverable by
supplementary insurance) for each visit to a physician or other medical service and the cost per hospital
visit has been increased from 14 Euros to 17 Euros.
These reforms were also aimed at reducing costs of the healthcare system to the government,
as can be seen by the slight increase inthe costs mentioned, and to do so three out of five physician
unions have voluntarily signed a contract indicating a commitment to change prescribing practices to
reflect a desire to reduce expenditures. Doctors are now strongly encouraged to prescribe generic drugs
in an effort to reduce pharmaceutical prices. An electronic medical record for every patient and
physician has also been implemented, and the creation of a High Health Authority has been
accomplished to advise UNCAM and the French government on technical health concerns and costson
evidence-based recommendations.
Conclusion
When compared to the French healthcare system, the United States has much to learn in terms
of organization, cost control, and universal coverage. Recent reforms of the NHI have demonstrated a
continuing willingness by the French government to fulfill the threebasic principles accepted by default
by the citizens it has been elected to govern. By insuring almost 100% of the French citizenship, these
reforms form a stark contrast to the current United States healthcare system where 30% of citizens are
without any form of health insurance whatsoever, these percentages translate into almost 33 million
Americans and only 200-500 thousand French being uninsured, pre-reforms, at any given moment in
time. One can gather from such facts that the NHI seems to be more effective at covering, insuring and
taking care of the French citizens than the current system of numerous types of MCOs in the United
C
nt [B47]: Repetitive. Creation of
created. Id scrap this part or the created part
C
nt [B48]: More repetition. Id revise
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States seem to be able to do. As an addedbenefit, the NHI looks to be simpler to navigate as a direct
result of its centralizations and cheaper as well, with it taking only 10% of the GDP versus the 15%
required by the current American health system. It may be said that it is thus imperative for the United
States to take up a similar program of insurance, especially when such results are taken into account as
the American peoples response to Furthermore, the American people seem to exhibitGallup Polls with a
shift in support for change. Indeed, implicit acceptance of certain French principles, such as the concept
of liberal medicine and perhaps even social solidarityhave been displayed as well. Indeed with the ,
polls such as those brought about by the Gallup Pollshowshowing a clear indication by the American
people to change the current system in a way that will reduce costs, allow the freedom to choose
between physicians, and provide a minimal coverage for all Americans.In continuation with the debate
on healthcare, United States politicians have fortunately begun to take note of the current problems of
healthcare, as in the case of Peter Orszags testimony before Congress, and have brought the issue to
the forefront of the political tablethus making the debate on the practicality, morality and
constitutionality of National Health Insurance a forefront of the public mind. It is now up to the
American people to decide whether to accept the conclusions of this and numerous other papers that
national health insurance is simpler, cheaper and more effective than the prevailing form of insurance
available in the United States today.
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Works Cited
Freeman, R. (2000). The Politics of Health in Europe.Manchester: Manchester University Press.
Jonas, S. (2003).An Introduction to the U.S. Health Care System Fifth Edition. New York: Springer
Publishing Company.
Orszag, P. R. (2008). Growth in Health Care Costs. Retrieved November 10, 2008, from Congressional
Budget Office: http://www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthTestimony.pdf
Rodwin, G. V. (2002).The Health Care System Under French National Health Insurance: Lessons for
Health Reform in the United States. Retrieved November 2, 2008, from PubMedCentral:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1447687
Saad, L. (2007).No Increase in Public Pressure for Healthcare Reform. Retrieved November 2, 2008, from
Gallup Poll: http://www.gallup.com/poll/4708/Healthcare-System.aspx.
Wikelius, K., Haase, W. L., Liebert, J., Kendall, A., Leiken, K., Mahar, M., et al. (2008).The Basics: National
Health Insurance Lessons from Abroad.New York City: The Century Foundation Press.
Young, K. M., & Sultz, H. A. (1999). Health Care USA Understanding Its Organization and Delivery Second
Edition. Gaithersburg: Aspen Publishers, Inc.
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