As the U.S. presidential candidates debate reforming Medicare, similar systems in France and Italy top a U.N. survey. Apart from their cost, their most important difference is offering citizens freedom from uncertainty.
By John-Thor Dahlburg, Richard Boudreaux, LA Times Staff Writers
CLERMONT-FERRAND, France–When Mathis Pascouret recently entered the world, something was dangerously wrong. His mother had unwittingly passed on to him potentially lethal bacteria while he was in the womb, and he was near death.
With a fever of 102 and his heart, lungs and stomach malfunctioning, the gasping newborn was whisked by ambulance to a state-run hospital here in central France. In the new neonatal emergency care unit at Hotel-Dieu Hospital, Dr. Jacqueline Gaulme and others toiled to save the infant’s life.
Nine days later, Mathis opened his eyes for the first time, and he is now expected to live.
“We should go down on our knees,” said his mother, Estella Pascouret, 29, “and thank the doctors and the hospital.”
For Americans, the real marvel in this story might not seem so much medical as financial. Mathis’ treatment costs an estimated 8,000 francs, or more than $1,000, a day. But his parents pay nothing.
“Eight thousand francs–it’s what I earn in a month,” said father Thierry, 38, who makes tires for motorcycles.
Since World War II, the French have deemed their health a national resource too priceless to leave to market forces alone and have instituted a state-run health insurance system that covers everyone. As Vice President Al Gore and Texas Gov. George W. Bush make Medicare reform a leading issue of their presidential race–they exchanged several pointed remarks at this week’s debate–the health care choices in France and elsewhere in Western Europe offer a stark contrast to those in America.
The most important difference is freedom from uncertainty. Despite flaws such as high taxes or slow-moving bureaucracies, government involvement in Europe gives the ordinary citizen an enormous sense of security. In many countries on this side of the Atlantic, people never have to worry about being deprived of essential health services–or prescription drugs, a hot-button issue in the U.S.–because they can’t afford them.
What’s more, unlike customers of many U.S. health maintenance organizations and health insurers, Europeans such as Estella and Thierry Pascouret can be sure they won’t be ruined financially because their health plan is unwilling to cover a particular treatment or pays only a part of the cost.
This year, a 191-country survey by the World Health Organization ranked France’s health care system the most effective in the world, with Italy the runner-up. Those ratings are disputed, even in the winning countries, but the survey’s bottom line is this: The French and Italians spend far less than U.S. citizens on health care, and they live longer.
The United States–which lays out a bigger share of its income on health than any other country, at 14% of all generated wealth–ranked 37th in the WHO survey, barely edging out No. 39 Cuba.
“I make my students watch episodes of ‘ER,’ ” said Dr. Andre Labbe, professor of pediatrics and respiratory diseases at the University of Auvergne medical school in Clermont-Ferrand. “They’re always stunned by what they see. On the last program, there was someone diagnosed with lung cancer who told the doctors: ‘Don’t bother to treat me. I can’t afford it.’
“That,” Labbe said, “is unimaginable in France.”While admiring the expertise of their U.S. counterparts, European health professionals can be scathing about what they call America’s money-driven method of dispensing health care. In France, the government doesn’t hesitate to throw its weight around to keep costs down by pressuring physicians, nurses and other care providers.
“The state fixes the level of contribution, reimbursement, the cost of drugs and prostheses–in fact, it fixes just about everything. In terms of the state’s mentality, the French system is a lot closer to [Soviet] Russia than to your system,” said Dr. Pierre Fender, a Paris-based official in the social security system.
A doctor’s house call in France is supposed to cost the equivalent of only $14.28, not including transportation, and a night in a private room in a medical clinic costs $73. Social security, funded mainly out of payroll deductions, reimburses 65% of minor expenses and 100% of major ones.
Italy, which finances its state-run National Health Service entirely from general taxation, keeps an even tighter lid on medical costs. As a result, total public and private outlays on health care and insurance come to $1,857 for each French man or woman and $1,357 for each Italian–a fraction of the $4,178 spent by or for the average American in 1998.
Even when an ill person can pay nothing at all, the health networks in these countries are supposed to react with competence and compassion.
France’s social security program was first restricted to the gainfully employed and retirees, but a 1998 law extended it to everyone on French soil.
“It’s a fact that when you need care in France, you go into a clinic or a hospital, and they’ll take care of you–take your blood pressure and try to see what’s wrong. They don’t ask for your credit card,” said Dr. Christian Pradeyrol, president and general director of a 250-bed private clinic in Aurillac, a town in Auvergne.
While millions of Americans worry about whether they can afford health care for themselves and their families, the French and Italians swear by a social contract that makes accessible treatment as much their birthright as being able to speak their minds or vote.
Although the notion that the state should be deeply involved in something as personal as health might be anathema to many Americans, such involvement is a long and welcome tradition in Europe.
Italy Pioneering a Home Care System
While the United States has few doctors who would even consider making house calls, and Congress has cut government payments for home health care generally in recent years, Italy has been pioneering a publicly supported system of free home care.
“Go to the patient. Don’t wait for the patient to come to you,” were the marching orders to doctors from Dr. Rosi Bindi, who stepped down as Italy’s health minister after overhauling the National Health Service to make it more responsive.
In practice, this means that Dino Coltelli, 88, who hated being hospitalized so much that he screamed at everyone around him and often escaped, can now rest easy while doctors and nurses come to his home in Imola in northern Italy. Diagnosed with Alzheimer’s disease, he has been treated during the weekly house calls for pneumonia, a urinary tract infection and a nervous disorder.
“Without this care, he’d be back in the hospital at least once a month,” said Dr. Fabio Suzzi, who sees Coltelli and eight to 10 other patients at home each week, earning a $75 bonus for each visit on top of his $4,000 monthly state salary.
The home care program, organized in 17 of Italy’s 20 regions, is an acknowledgment that the country’s most reliable giver of informal care–the family–needs some help.
As Italians have fewer offspring, become more mobile and live longer, the tradition of large extended families nursing their ailing elders has come under strain, forcing many senior citizens to face their last years alone.
Liliana Coltelli, 78, cannot care for her husband by herself, and the couple have no children.
Doctors in Imola and the surrounding Emilia-Romagna region, home to 4 million people, treat more than 15,000 patients at home, including 40% of all those with cancer. Regional officials say the home care program has cut hospital costs by $180 million in three years.
Retired people in the region lobbied hard for home care, fought for a role in monitoring the program and are pushing to double the number of senior citizens served.
“If you’re treated at home, you keep some control over your own life, your own dignity,” said Germano Casanova, secretary of the regional Pensioners Union. “If you enter a nursing home, that’s all finished. Not one elderly person in 100 ever walks out of a nursing home.”
Indisputably, many French and Italians would be the first to admit that their health care systems are far from perfect. Among the prevalent gripes: a surfeit of red tape, excessively high taxes or payroll deductions to underwrite the systems, delays and inequalities despite avowed noble goals, and the heavy hand of government bureaucracy.
This summer, when personnel from France’s state-run hospitals took their usual vacations, some patients being admitted to emergency wards had to wait as much as 10 hours on stretchers before being examined.
Martine Aubry, who until this week held the ministerial portfolio for health, complains that “in big towns, it’s hard to find a pediatrician onFridays after 5 p.m.” To make sure that not all doctors vanish at night and on weekends, Aubry has asked prefects–the national government’s representatives throughout France–to force all physicians to take part in an on-call rotation for emergencies.
Chafing under official pressure, some French doctors claim that politicians on both the left and the right have cooperated since the mid-1990s to craft an ever-tightening straitjacket of regulations and price ceilings that are now suffocating private practitioners and clinics.
“The state has got a noose around our neck, and we’re one twist away from asphyxiation,” protested Pradeyrol, 55, an anesthesiologist.
This summer, a plan backed by Aubry to hold down rising health costs, in part by cutting office visit fees paid to specialists such as cardiologists, radiologists, neurologists and gynecologists, sparked numerous protests, with 100 angry doctors occupying the Eiffel Tower one morning.
Prompt Service a Goal Often Unmet
Italy’s tax-financed system falls short of its goal to provide prompt service, from dental checkups to knee surgery, to all. For every tax dollar the state spends, Italians shell out 38 cents of their own for some kinds of specialized care that are more prompt or reliable.
Franco Bornini, a taxi driver in the northern city of Bologna, found that the waiting list to get free physiotherapy for his dislocated right shoulder was six months long. The injury has partly disabled him, reducing the hours that he can work. So he has resorted to a private therapist at $15 a week over 10 weeks–a financial burden, because he, like most Italians, doesn’t have private health insurance.
But the public system offers better care to the neediest–expectant mothers, the elderly and people with life-threatening ailments.
Some of this care borders on luxury. Patients who undergo heart surgery are entitled to two weeks at a rehab center near Lake Garda or Lake Como, prime vacation spots in northern Italy. They receive three hours of physiotherapy in the morning and relax in the afternoon, with the state paying the tab.
Nobody is supposed to fall through the cracks, even foreigners living in Italy illegally.
In Bologna, a publicly funded health center with Arabic and Chinese translators on staff has catered exclusively to immigrant women and their children for the past nine years. The center doesn’t even ask to see patients’ identify papers. Dr. Giovanna Caccialupa, the director, has rebuffed so many police inquiries about her patients that the police have stopped coming around–even during periodic official sweeps to drive illegal immigrants out.
“We’re treated like anyone else,” said an immigrant Moroccan mother waiting her turn at the clinic.
This sense of inclusion and security is more than what many immigrants feel in the United States, especially those who are in the country illegally.
Many of the latter say they are afraid to avail themselves of the health care system for fear that information about them will be reported to the police and that they will be deported. In three-quarters of Italy’s regions, health officials have set up 138 public health clinics, nearly all in the past five years, especially for immigrants.
Statistics point to a clear impact on Italy’s overall health. In part because of intensive efforts to provide prenatal and postnatal care to all mothers, the country’s infant mortality rate has fallen to 5.6 deaths per 1,000 live births. The U.S. figure is 7.2 deaths.
“We in the United States do worse than our European counterparts in the area of prenatal care, both for immigrants and minorities,” said Dr. Christopher Murray, an American who heads WHO’s health policy program.
French System Tries Reconciling Aims
In France, 30 chronic and especially costly medical conditions, from Alzheimer’s disease and AIDS to diabetes and psychiatric ailments, are fully covered by a hybrid health care system that tries to reconcile a patient’s right to choose a doctor with a pledge of universal coverage.
Moreover, operations or other medical procedures costing more than about 600 francs ($77) are paid for.
“Six hundred francs–that’s the cost of a wrist fracture,” remarked orthopedic surgeon Pierre Deguillaume.
When interviewed, the perspiring Deguillaume was at work in an operating theater at the Aurillac clinic, removing a stainless steel brace from around the backbone of an anesthetized 25-year-old pharmacy clerk. The operation took two hours, plus Deguillaume had to make an earlier run to a local hardware store. The brace was U.S.-made, and he needed a non-metric wrench to undo the nuts and bolts.
“There is no cost for any of this to my patient. Everything is picked up by social organizations,” Deguillaume said.
For chronically unwell patients who face lifelong expenses, the certainties of such a health system bring enormous comfort.
Take French retiree Roger Martin, 75, whose failing kidneys can no longer purify his blood. Once every two days, the retired electrician and TV repairman who used to have a shop in the town of Montlucon in the heart of France is picked up by a taxi and driven 40 miles for a four-hour dialysis session.
Each treatment costs the equivalent of $267, not including $130 for round-trip taxi fare. Martin pays nothing. For 55 years, he made mandatory contributions to the social security system, or la Secu, as the French call it. The health program now pays for his dialysis sessions, including cab fare.
“I know there are problems over there with hospitalization and the costs,” Martin said as he rested on a bed after a dialysis session. “But when we come here, they take us in their arms and care for us. There is always a smile.”
In the United States, both leading presidential candidates have come up with proposals to change Medicare, which pays for many of the health care costs of 39 million elderly and disabled Americans. While both candidates propose increasing prescription drug coverage, only Gore would have the government pay a major part of the cost of the coverage. About 13 million elderly and disabled Americans have no coverage at all for prescriptions.
A Uniform Approach to Prescription Drugs
Italy’s National Health Service gives full coverage for about 3,000 prescription drugs, including the big-ticket categories: blood-pressure medicines, chemotherapy, drugs for diabetes and HIV/AIDS, plus a full range of antibiotics. Patients have to pay 50% of the cost of a second category of 38 drugs for such ailments as stomach disorders, aching joints and kidney stones.
In the United States, there is no uniform system of insurance for prescription drugs. While most people younger than 65 who have health insurance pay only a $10 to $20 co-payment for most prescriptions, 13 million elderly and disabled people and 44 million people younger than 65 have no insurance at all. For those who are uninsured, a common ulcer drug such as Prilosec if bought in Los Angeles costs as much as $133 for a one-month supply, according to a 1999 study by a California member of Congress. Prices, however, vary by region, as do insurance plans.
In France, the totally infirm older than 60 are entitled to medical care in nursing homes at state expense, while conditions classified as recurring and costly are fully covered for young and old alike. Drugs for such ailments are fully paid for by social security. For others, the reimbursement rate is 65%.
To reduce even further the chance that disease might have financial repercussions, almost nine French people in 10 buy private health insurance to cover minor expenses that aren’t taken care of by social security. But the bulk of the country’s doctor and hospital bill–75.5%–is paid by la Secu.
Andre Calsac, 75, a former notary in the Champagne region of eastern France, is in his fourth week of chemotherapy and radiation treatment for cancer of the lymph glands. His treatment is fully financed by social security–including the pain-dulling morphine he is given each day.
“It’s all in the hands of the health insurance and the doctors,” Calsac said. “I don’t have to do anything.”
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Dahlburg reported from Clermont-Ferrand and Boudreaux from Emilia-Romagna. Times staff writer Alissa J. Rubin in Washington contributed to this report.
Copyright 2000 Los Angeles Times