France on $3,000 a year.

Author:Kodmani, Hala

PARIS -- In the visitors' book of the exhibition "Humanization of the Hospitals," one recent comment observed: "In this museum you're in a dream ... It's so different from the hospital I have to return to next week." This exhibit of what French hospitals ought to be is essential. The French public may seem like they are all too often persuaded that their health care system--so praised and envied abroad, held up as an example even among other developed countries--is one of the best in the world. This isn't the case.

France spends 11 percent of its GDP on health care, second only to the United States among OECD countries. That's some $3,601 per capita each year, with a public health insurance program that covers 99.9 percent of its population. Almost every French citizen or resident holds a green card, the "Carte Vitale," which gives access to an efficient and state-of-the-art health system. This electronic proof of coverage carries an individual's personal information, and by handing it off to a medical center, laboratory, public hospital, private clinic, or even drugstore or physiotherapist, a patient can get whatever treatment may be needed, often without spending a single euro. Health care professionals are then automatically reimbursed on the basis of fixed rates for each service or product by the securite sociale, the public health insurance system, which covers 60 to 100 percent of all costs. The balance is usually reimbursed by a private complementary insurance company or a mutual fund. Almost all French citizens covered by public health insurance are also affiliated with private, supplementary policies, connected to the government system. Together, they are meant to work seamlessly and cheaply.

But to get total and immediate free coverage, it's better to be very poor, very sick or very old. A lower-middle class, middle-aged worker suffering from a minor flu or stomach ache will find the system lacking. Each visit to one's primary care physician--a required first step to enter the process of coordinated care--costs $26. The patient is immediately responsible for the [euro]8 not covered by the federal securite sociale, then waits for possible reimbursement from their private policy.

Cashing Out

"For some low-income people, these small co-pays can be a deterrent--either not to go to the doctor or to postpone the visit," says Dr. Mady Denantes, a general practitioner working in the 20th arrondissement of Paris, one of the poorest neighborhoods in the French capital. She tells the story of Marie, 45, a laborer earning the minimum wage of $1,434 per month, who eventually came to see her after long weeks of pain in her legs.

"She was just asking me to prescribe a sick leave, so she could rest for a few days. I gave her a paper entitling her to sick allowance while on leave but also prescribed further tests, including X-rays and blood tests," Dr. Denantes recalls. "Marie came back to see me a few months later with the same pains but without having done the tests I had prescribed. She explained reluctantly that she was part of a very small minority of French workers who have chosen not to subscribe, for cost reasons, to a...

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