French health system gets surgery

France offers its citizens the best healthcare in the world, and it isn't only the French who will tell you so. The World Health Organization ranks France at the top of its list.

The trouble is, the country cannot afford it. The French public health insurance scheme is heading for a $15.5 billion deficit this year, threatening to bankrupt the system.

"Our health system has gone mad," Health Minister Philippe Douste-Blazy told a parliamentary commission earlier this month. "Profound reforms are urgent."

But as trade unions rally in defense of free healthcare for all, the topic has become the hottest issue on the government's controversial reformist agenda, threatening further unpopularity as European parliamentary elections approach.

France is not alone in finding it increasingly hard to fund cradle-to-grave welfare systems. Across Europe, aging populations and ever more expensive medical treatments are busting budgets. The German government recently scandalized voters by introducing small charges for doctor visits and medicines.

Europeans' attachment to their public healthcare systems is strong, however, and nobody wants to see privatization. Even the conservative French government, keen to reduce the state's role in citizens' lives, has pledged to ensure "equal access to healthcare ... the central pillar of our republican pact" based on a "public and universal health insurance system," in Mr. Douste-Blazy's words.

The minister unveiled his plans Monday, estimating that the nation could save $18 billion a year: Reforms included computerizing patient records, encouraging patients to visit their family doctors before going to expensive specialists, boosting the use of cheaper generic drugs, and making patients pay a nominal $1.19 charge for each visit to a doctor.

That charge "is more a sign of taking responsibility than a real financial issue," Douste-Blazy said, aimed at making people realize that healthcare does cost money, even if citizens don't pay for it directly. "It is essential that going to the doctor should cost something, to make people realize what they are getting," says Bruno Fron, a general practitioner in Paris.

The French system - with its efficient hospitals, plentiful doctors, short waiting lists, and universal benefits - works on a system of compulsory insurance. Everyone who works pays a share of salary to the social security fund (more than matched by his employer), which pays 75 percent of the cost of all normal medical procedures. Since most people top up their insurance with profession-based funds, 100 percent of their medical costs, including medicines, are reimbursed automatically.

Since it does not cost patients more to visit as many doctors as they like as often as they like, the current system tends to encourage overconsumption, health analysts say. The French go to the doctor twice as often as Swedes, for example. The government hopes to cut down on excess by computerizing each patient's medical records and making them accessible through individualized cards. That would allow a doctor to see whether the examination a patient was requesting had already been carried out, for example, or whether someone had already visited several other doctors in unsuccessful bids for sick leave authorization.

"We need to bring healthcare into the 21st century," says Elisabeth Docteur, a health economist with the developed countries' Organization for Economic Cooperation and Development (OECD)in Paris. "Until data is automated and easily shared ... there will always be significant inefficiencies."

The new emphasis on generic drugs also "offers a great opportunity for savings," says Ms. Docteur, especially since the French consume more medications than any other nation in Europe. Pharmaceuticals account for 21 percent of the country's total spending on health, compared with 12.4 percent in the US and 14 percent in Germany, according to OECD figures. A government study earlier this year found that the French take nearly four times more tranquilizers than their neighbors, and that 350 people a day are hospitalized due to toxic interactions between prescription drugs.

This massive consumption of medicine, says Francois Joliclerc, an expert who helped write the government study, "is due to old bad habits in doctors and patients. It's a vicious circle," he says. "The more medicines a doctor prescribes, the more patients think they are doing them good, and the more they demand."

The government has begun to attack this consumption culture, launching an advertising campaign during the last coughs-and-colds season with the slogan, "Antibiotics - It's Not Automatic."

"I cut my prescriptions of antibiotics in half last winter," says Dr. Fron. "I didn't have to fight; my patients understood when I told them that antibiotics were not what they needed."

Trade unions complain that the plan puts most of the burden on patients, rather than asking employers to chip in with higher taxes. Some health experts, meanwhile, worry that the government's plan to make it more expensive to go straight to a specialist, without referral by a family doctor, means specialists will give preference to wealthier patients who can afford to pay higher fees to jump the line.

Douste-Blazy, however, sees the real danger of preferential treatment for the rich in a collapse of the current system. "Two-speed medicine is exactly what we have to avoid," he said on French radio Wednesday, pledging his support for universal health insurance. "And the way to avoid it is not to lose money every year."