Cheese-Eating Surrender Monkeys
In this series, an American in Paris pits the French welfare state against the U.S. market economy in five key categories: childbirth and health care, preschool, higher education, immigration, and shopping.
When I got pregnant with my daughter, I had been living in France for only about six months, and hadn’t yet received my Carte Vitale, France’s universal health care card. The day I went for my first sonogram, my midwife warned me that I should brace myself for a big bill. “Since you don’t have your Carte Vitale yet,” she said, “it’s going to be costly.”
I’m an American, and accustomed to American medical costs—I’d always worked for small businesses, where company insurance usually came with high co-pays and out-of-network deductibles. So of course I tensed up. “How much will it be?” I asked the midwife fearfully. “Will it be—more than 1,000 euros?” (That’s about $1,300 at today’s exchange rate.)
She looked at me like I was crazy. “No, it won’t be that much!” she exclaimed.
The final bill for the appointment was 150 euros, or about $200, which I paid in full, and for which I was later reimbursed in full.
In other words, “$200 minus $200” counts as a “costly” medical bill in France.
France is a proud welfare state, where public spending accounts for 53 percent of GDP—the second-highest percentage in the developed world (only Sweden’s is higher). The U.S. is the third-lowest, at 36 percent (ahead of Ireland and South Korea). Having a baby so soon after moving to France gave my husband and me a crash course in one of the largest components of the French welfare state: its medical system, which has often been called the best in the world.
France’s health care system is a public/private hybrid: Everyone is covered to a certain extent by the government’s Assurance Maladie, but most people also have private insurance, called a mutuelle, that is either offered through their employer or bought on the private market. There’s a thriving private insurance market in France—one that the Affordable Care Act can only dream of. Private medical insurance is advertised on the sides of buses and alongside movie previews in theaters, and there are plans geared towards numerous niches: college students, freelance professionals, and people who work in restaurants, to name a few.
Because my husband worked at a French company, he immediately began paying into the system, which covered me as well while I wasn’t working. In addition, my husband’s employers provided a choice of mutuelle; the top-of-the-line plan, which we signed up for, cost about 50 euros ($68) a month. By contrast, in the U.S., I’d been paying about $350 a month with an additional $50 co-pay for each doctor’s appointment.
Our first task was to find a place to have the baby. I’d suspected I was pregnant for two weeks before I took a pregnancy test, not wanting to be overly anxious. This was my first mistake. “You must call the maternités now—vite! Vite!” my friend Anais practically yelled at me when she heard. And she was right: Six weeks pregnant, I was already too late to get a spot in many of Paris’ public maternity wards. Only then did I learn that most Parisian women call the hospital the day they miss their period. I have a friend who walked to her local hospital with her pregnancy test in hand the minute she found out.
This kind of crowding, especially in bigger cities, is one of the downsides of a government-run health care system. On the upside, had I managed to book a bed in one of the public wards, my birth would have been completely free, paid for entirely by the government’s Assurance Maladie. Everyone pays into Assurance Maladie through charges that are taken directly from their paycheck. (Unlike Americans, French employers and workers quote salaries as net, not gross—so your salary is what you receive after deductions for health care and other social services.) From the sixth month of pregnancy to 11 days after a child’s birth, the government covers a woman’s medical expenses in full.
In full—except for the costs of a private clinic if you’ve missed out on a public ward. There are plenty of private maternités in Paris, and I found a great one, with an English-speaking midwife who agreed to follow my pregnancy from the outset, as I still had no regular doctor. But how expensive would it be?
Luckily, transparency in the price of medical care is a legal requirement in France. The government sets what they consider fair prices for all appointments and procedures, and then reimburses these for everyone at 70 percent. This is not unlike Medicare and Medicaid in the U.S., but because the French government system covers the entire population, it has more bargaining power to keep prices low. For example, a private appointment with a midwife is calculated at a base cost of 28 euros—the same price it would be at a public clinic or hospital. The government will reimburse the patient 18.50 euros of this, even if the midwife charges more; the rest the patient pays out of pocket and/or has covered by a mutuelle.
It’s not uncommon in the bigger cities, particularly in Paris, for a doctor to charge more than the government’s recommended price. But these overages, calleddépassements, don’t come anywhere near what an American specialist might charge. In fact, under French law, a doctor must issue a receipt explaining any dépassementabove 70 euros before beginning the test or appointment. (France is also arguably more creative than U.S. health care providers in keeping childbirth costs down. For example, women who are likely to have complication-free births are usually referred to a Level 1 maternity ward, which has an operating room in case a C-section is necessary but no neo-natal unit or full hospital facility attached to the clinic. In the U.S., most women deliver at a full-service hospital, even if it’s likely they will experience no complications.)
Not only was I getting accustomed to a radically different idea of what constitutes “expensive,” but I was also adjusting to the outlandish notion that I would know the exact cost of my health care services before buying them.
In the U.S., meanwhile, it’s often impossible to get a price for a delivery out of a hospital. Estimates vary by orders of magnitude: This California study of 100,000 complication-free deliveries showed that new mothers were charged anywhere from $3,296 to $37,227, with no clear medical reason for the massive discrepancy.
By contrast, for my complication-free delivery and five-day stay in a private clinic, my total out-of-pocket cost was 400 euros, or about $542.
Last fall, I watched the rollout of the Affordable Care Act with great interest from across the Atlantic. I’m self-employed, and I’m just not sure how my husband and I would have been able to pay our medical bills under the old system if we’d stayed in the U.S. The ACA is an improvement, but I don’t think we should count Obamacare’s average monthly premium of $328 as a success. That’s still a lot of money for a middle-class family—and that’s before co-pays, in-network deductibles, and all manner of hidden costs. From my French-ified perspective, a single-payer system—with strong government oversight to keep the price of medical care low—seems like the only way to go.
A final note: If you have a baby in France, expect to bring your own towels to the hospital. While there are no $10 aspirins, there’s not much in the way of other amenities, either. But for great, affordable health care, I’m just fine with bringing my own shampoo.