Ladies and Gentelmen, I give you France

(cross posted from tpm)

A substantive debate has been circulating tpmcafe and other corners of the web among us health policy wonks and what we deem to be the Right Way to go about fixing our health system.

But there appears to be some discrepancy among the policy wonks when using the term “single payer”.  Some mean pure single payer, or a Canadian or UK style way of delivering care, where there is no or a very small role for the private sector.  Others are making “single payer” synonymous with “universal care”, which is a different issue indeed.

Although some have argued otherwise, I think the one thing nearly all (>95%) progressives agree on that we need to have universal health insurance.  Not that all health insurance and health care services should be funneled through the government, but every single person in the United States should have health insurance, and if necessary the government should step in to fill in the gaps.  That is the baseline of agreement.

From there, you get any number of ways to achieve it.  Hence the quibbling among PPI and Kevin Drum about incrementalism.  Then there's the question of whether or not we should adopt a true single-payer system.  On that front, Leif Wellington Haase wrote an excellent meditation on why we should be cautious with single payer, and today Ezra Klein has a good look at why Canadian-style health care should not be our goal in the United States.

Instead, a better model for the U.S. would be a public-private hybrid that provides a floor of care and universal coverage for everyone, along with varying levels of benefit packages offered by the private sector. 

But what would this kind of system look like, and does it work?  France is one nation with quality results within a public-private framework, and a look at this system is a sound place to start.   

Everyone in France has a basic level of publicly-funded insurance.  This insurance covers everything and makes no demands on physician choice (or the number of tests or visits).  These public funds cover 75% of health costs, with the rest of the cost split between out of pocket payments and private insurance.  85% of the population has a form of supplementary insurance to cover the rest.  All doctors in France take either public or private insurance, so there’s no migration of doctors toward one avenue or the other.

There’s a few things about the French system that address single payer concerns Leif laid out:

• Because of the allowance for a private sector, the development and adoption of technology won’t be stifled

• Private insurers will stay around because they’ll still have “skin in the game”, thus avoiding a complete administrative disaster

Again, the most important goal is to cover everyone.  Once a plan allows for that, we need to examine the ways it can hold down costs. In the case of France, that’s done in many different ways.  Two of the main controls:

• Because the majority of health spending is directly financed by the government, it has great bargaining power to ensure lower prices (think the right way to do Medicare Part D)

• The state plans hospital locations, ensuring a uniformity of available care

And the French system was given the number one rating by the World Health Organization in 2000.  Where did the United States stand? Number 37. 

As Leif said, there are many ways to Rome.  But France represents a well-traveled and smoothly paved avenue. 

Comments

[Martha Grant]

In the single payer vs. incrementalist debate, I think it's important to note what has actually been happening around the United States. For instance, in NY state the Working Families Party is currently working to get a bill passed for their Fair Share for Health Care campaign. Single-payer is great theoretically - but getting more people covered in the meantime is vital. Check it out!