摘要：The French health system combines universal coverage with a public–private mix of hospital and ambulatory care and a higher volume of service provision than in the United States. Although the system is far from perfect, its indicators of health status and consumer satisfaction are high; its expenditures, as a share of gross domestic product, are far lower than in the United States; and patients have an extraordinary degree of choice among providers. Lessons for the United States include the importance of government’s role in providing a statutory framework for universal health insurance; recognition that piecemeal reform can broaden a partial program (like Medicare) to cover, eventually, the entire population; and understanding that universal coverage can be achieved without excluding private insurers from the supplementary insurance market. THE FRENCH HEALTH CARE system has achieved sudden notoriety since it was ranked No. 1 by the World Health Organization in 2000. 1 Although the methodology used by this assessment has been criticized in the Journal and elsewhere, 2– 5 indicators of overall satisfaction and health status support the view that France’s health care system, while not the best according to these criteria, is impressive and deserves attention by anyone interested in rekindling health care reform in the United States (Table 1 ▶ ). French politicians have defended their health system as an ideal synthesis of solidarity and liberalism (a term understood in much of Europe to mean market-based economic systems), lying between Britain’s “nationalized” health service, where there is too much rationing, and the United States’ “competitive” system, where too many people have no health insurance. This view, however, is tempered by more sober analysts who argue that excessive centralization of decisionmaking and chronic deficits incurred by French national health insurance (NHI) require significant reform. 9, 10 TABLE 1— Health Status and Consumer Satisfaction Measures: France, United States, Germany, United Kingdom, Japan, and Italy France US Germany UK Japan Italy Health status Infant mortality (deaths/1000 live births), 1999a 4.3 7.2b 4.6 5.8 3.4 5.1 LEB (female), 1998a 82.2 79.4 80.5 79.7 84.0 81.6c LEB (male), 1998a 74.6 73.9 74.5 74.8 77.2 75.3c LE at 65 (female), 1997a 20.8 19.2 18.9 18.5 21.8 20.2 LE at 65 (male), 1997a 16.3 15.9 15.2 15.0 17.0 15.8 Severe disability-free life expectancy (female), 1990/1991d 14.8 NA NA 13.6 14.9 NA Severe disability-free life expectancy (male), 1990/1991d 18.1 NA NA 16.9 17.3 NA Potential years of life lost per 100 000 population (female), 1993e 2262 3222 2713 2642 1914 2136 Potential years of life lost per 100 000 population (male), 1993e 5832 6522 5752 4688 4003 4873 Consumer satisfaction, % Only minor changes needed, 1990f 41 10 41 27 29 12 Very satisfied, 1996g 10 NA 12.8 7.6 NA 0.08 Fairly satisfied, 1996g 55.1 NA 53.2 40.5 NA 15.5 Open in a separate window Note . US = United States; UK = United Kingdom; LEB = life expectancy at birth; LE = life expectancy; NA = not available. a Source . Organization for Economic Cooperation and Development. 6(p27) b1998. c1997. dDefined as life expectancy with the ability “to perform those activities essential for everyday life without significant help.” 6(p27,31) e Source . Organization for Economic Cooperation and Development. 6(p30) f Source . Harvard–Louis Harris Interactive 1990 Ten-Nation Survey, cited by Blendon et al. 7 g Source . Eurobarometer Survey, 1996, cited in Mossialos. 8 Over the past 3 decades, successive governments have tinkered with health care reform; the most comprehensive plan was Prime Minister Juppé’s in 1996. 11, 12 Since then, whether governments were on the political left or right, they have pursued cost control policies without reforming the overall management and organization of the health system. This strategy has exacerbated tensions among the state, the NHI system, and health care professionals (principally physicians), tensions that have long characterized the political evolution of French NHI. 13– 15 Although the French ideal is now subject to more critical scrutiny by politicians, the system functions well and remains an important model for the United States. After more than a half century of struggle, in January 2000, France covered the remaining 1% of its population that was uninsured and offered supplementary coverage to 8% of its population below an income ceiling. 16 This extension of health insurance makes France an interesting case of how to ensure universal coverage through incremental reform while maintaining a sustainable system that limits perceptions of health care rationing and restrictions on patient choice. Following an overview of the system, and an assessment of its achievements, problems, and reform, this article explores lessons for the United States of the French experience with NHI.
