How to have the best health and health care in the world.
How to have the best health and health care in the world.
By Ian Morrison
The French have the best health care system in the world. Just ask them. (According to them, they have the best everything in the world, from cheese to lifestyle.) Yet, the World Healthcare Organization and many other international comparative analyses actually do agree that the French are healthy and that the French health system is at, or close to, the top of the list in performance. Are there any lessons that we can learn from France?
Decoding French Culture
All health care systems around the world are a reflection of the values and culture of the country. So you can decode the health care system only if you try to understand the culture. On a recent visit, I did my best to immerse myself in the language and culture to try and interpret why the French seem to be so healthy and do so well in the health care comparison stakes. This involved a lot of wine and smelly cheese.
Here are some clues:
The country is in a superior location. France is geographically situated as a perfect hexagon (L’Hexagon, they call it) in the temperate zone of the northern hemisphere, which gives the country beautiful vistas, rich arable land and the finest products of the countryside. From the cheese of Normandy to the olives of Provence and all the wine in between, France has killer natural groceries. Even the poorest peasant (read “guy who just sold his little farm to some chinless Brit hedge fund manager”) knows what good organic food is (they call it biologique).
Even the chain supermarkets are filled with dead chickens with their heads still on. If you ask for ground beef (don’t ask for hamburger, they will know you are American), they actually take a piece of beef and grind it up in front of you. This is at the equivalent of Safeway. In most American supermarkets a pound of ground beef could conceivably be sourced from many different cows, in many different countries. So they eat better in France. While we subsidize big agro business to make high fructose corn syrup (the true weapon of mass destruction in our society), the French subsidize little farmers to grow chickens with their heads still on and to make an enormous variety of smelly cheese.
They have superior education. France has an incredibly meritocratic education system in which the top of the class moves up the educational hierarchy so that if you make it to the top you really are the smartest people in France. Since the French are the smartest people in the world (in their assessment) and their system is meritocratic, by definition anything that these smart people decide has to be the right thing to do. Very Descartes.
The French are smarter than the market. (Or so they think.) You see this everywhere in France: A spectacularly engineered, uniquely French solution is carefully crafted to deliver superior performance; but it is weird, idiosyncratic and completely lacking in export potential. Renault Espace mini-vans can be driven for hundreds of miles at fantastic speed, on a single tank of diesel, but I defy you to operate the parking brake. They don’t sell in America.
They have a superior lifestyle. The French believe their country and their lifestyle are superior, and it seems that much of the French economy is focused on lifestyle maintenance. This ranges from the billions of euros spent polishing French roads and villages, to the parades of guys in Paris who are dedicated to cleaning the streets and ridding the sidewalks of merde du chien.
My personal favorite lifestyle maintenance policies are the combination of regulation and subsidies that exist to maintain French eating habits. For example, in every Paris neighborhood there has to be at least one boulangerie open to sell fresh bread every day (this means a bakery can close Sunday or Monday but not both, and bakeries have to coordinate this with their geographic competitors). The price of a baguette is set by law!
Similarly, the French have a system of lunch money subsidy in which employers can give lunch coupons to employees that are tax deductible so that an employee can afford to go to some brasserie for moules frites and a carafe of wine for an hour and a half, every work day. The goal is to keep the brasseries open and not let McDonald’s get the business. But let’s face it, if you had a moules frites subsidy and a mandatory 35-hour week, you’d live a long healthy life, too.
They drink wine in moderation. French kids learn to drink wine at an early age, usually watered down. Decent Vin du Pays is cheaper than Coca-Cola in most restaurants and supermarkets. The French (like most Europeans) learn how to drink before they learn how to drive. In America, we unleash 15-year-olds on to the streets in SUVs so they can drive to Safeway with their fake ID, but they can’t have a glass of wine with a meal until they are 21. No wonder we have an entire generation of college graduates who are not sure what happened in college because of the Jäger bombs.
No stress: They don’t sweat the big stuff. In the early 1990s a colleague and I were giving a briefing in Paris to a big fancy French company explaining how because of globalization, the American wave of re-engineering would eventually hit France and require tough choices, a dedication to efficiency, and streamlining of business processes. An incredulous French executive barked back at me: “Why would we do that? It will ruin our life!” He had a point. While we in the United States have driven ourselves into a frantic Blackberry orgy of overwork over the last two decades, the French are still pretty chill.
They sweat the small stuff. The French do worry like crazy, but not about big things like war, their job, fidelity and so forth; they obsess over the small stuff. Every French movie has a scene where a bunch of people are sitting around eating in someone’s kitchen and the dialogue goes something like this:
“The peaches are not so fresh today, Jean Claude.”
“You are right, the peaches we had yesterday were much fresher, but they came from Auvergne. These peaches did not come from Auvergne, you know…”
This conversation goes on for another 15 minutes, and American audiences watching the movie have dozed off reading the subtitles, their popcorn strewn across the floor. But the French love worrying about this kind of stuff; it is like therapy for them.
They walk. Parisians walk. Take the Metro. Walk. When Madame goes to the village for the second time that day, for another fresh baguette for the evening meal, she walks. My wife noticed that all the under-30 women in Paris are in sensible but stylish flat shoes, ready for long hours on the pavement. Even though aging French Dolly Birds are still sporting high-heeled boots for the winter, they are still walking in them.
They walk upstairs. The average American MRI is larger than the average Parisian elevator. While we in the United States are supersizing our MRIs and hospital beds (even to the point of installing ex–Port Authority cranes to get the patients out of bed), the French make the elevators so small and claustrophobic that overweight people like me are forced to take seven flights of stairs to the apartment. (This happened.) Voilà, we are thin.
They use public transit. From the Paris Metro to the spectacular TGV (high-speed train), French of all socio-economic strata use public transport. The TGV hurtles through the beauty of the French countryside at 200 miles an hour, and you arrive relaxed. This sure beats hurtling through Trenton on Amtrak or schlepping through O’Hare. And when they get off the train? You guessed it: They walk.
They get naked in the summer. If you visit the beaches of St. Tropez in the summer, you will indeed encounter the topless Eurotrash tottering around on tiny heels, on the arm of the Russian mob oligarchs who now rule the South of France. But, mostly, you see naked middle-aged people. Way too much information. However, getting naked every summer in front of your Gallic peers is a powerful motivation to keep the BMI in check.
They smoke. Sure, they don’t smoke as much as they used to, and smoking is now outlawed in restaurants, bars and all public places, but you still see a lot of smokers, particularly young people, and they are thin. (This phenomenon is most pronounced in Croatia where young people look like they came from the United States in the 1970s, a full 30 pounds smaller. It’s like a time warp back into an episode of Charlie’s Angels.)
They take drugs. The French are the highest consumers of pills in the world. The pills are cheap because the French tightly regulate pharmaceutical prices for most products unless they are truly innovative. (Some cynics might say that innovative means “made by French drug companies”; see “They have superior education,” above.). The green crosses of French pharmacies are everywhere in France: from every block in Paris to every village in Provence. And pharmacists can prescribe many medications. France has lots of little special medications for the liver, and you will always see Monsieur popping a little pill or two after the cheese plate to aid the digestion.
They revere liberté, egalité, fraternité. The French like liberty as much as we do; indeed, they gave us a statue about it. But they are also big on equality and fraternity. The more contemporary term in Europe is “solidarity,” which is the recognition that certain key dimensions of society such as health care, education and transportation are collective goods that need to be supported by all, for the benefit of all. Over the last decade or so in the United States, we talked a lot about liberty. Fraternity, not so much.
Alors, you got it. The French are different from us. We won’t have the same health status as the French because our values and culture are different. We are a little too hard working, money-obsessed, frantic and unequal to have the French lifestyle. But, what about the French health care system? Is there anything we can learn from them that is translatable, given the wide cultural differences?
A Translation for America
T.R Reid’s excellent recent book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin Press, 2009), is a wonderful review of how many other industrialized countries provide health care that is less expensive and fairer. From his work, here are a couple of ideas we should think about that don’t actually require us to turn French.
Carte Vitale. The French have a ubiquitous electronic smart card called Carte Vitale that contains basic health information on the patient. It is really a portable electronic health record and insurance card. Doctors also swipe it through a card reader for billing purposes. There are no billing clerks in the doctor’s offices because it is all automatique, as Reid’s French doctor would say. It’s all very French proprietary technology. The French are big on smart cards and little card readers that they design and manufacture, but the basic idea is right: Everyone should have a card they carry about that with one swipe conveys the essential patient information and links to your health insurer.
Normally in the United States we embody the intelligence in the network, not in the card, but given the billions being spent on health IT, surely to God we can have a system in which at least the doctor knows you are allergic to penicillin and the billing part is taken care of. I really want to see an end to the pathetic U.S. ritual that takes place in most doctors’ offices: The receptionist takes your health insurance card and makes a copy of it, both front and back. In the age of Google this ritual is positively medieval.
Skin in the game and price transparency, French-style. As Reid explains, the French require insurers by law to reimburse doctors and patients within a timely manner (usually within three days). But here’s the good part: The French system expects patients to pay something at the point of care and, indeed, as Reid explains: “most French patients, in fact pay the full charge of treatment at the point of service.” There is a detailed price list in every office; you, the patient, pay with your own money at the point of care; you know what the deductible and cost-sharing will be, because the Carte Vitale knows; you put down you euros; you get the service; and what you are being reimbursed has to be paid to you by the insurer within three days.
Contrast this with the bizarre, gotcha, after-the-event, surprise you get when encountering American health care. You don’t know until it’s over what you just bought and for how much. It’s like the New Jersey freeways: The exit signs are after the exits.
So in conclusion, read T.R Reid’s book for more great insights on France and other health systems. There are countless lessons on how to make health care fairer and cheaper that we could easily adopt for American consumption. And if you really want to be as healthy as the French: Walk, eat cheese, drink wine, throw away your Blackberry and get naked in the summer…but, please don’t smoke. As the French cigarette labels say, Fumer Tue (Smoking Kills).
Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Weekly and a member of Health Forum’s Forum Faculty Speaker Service.