Book Discussion - <i>Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France</i>

On Thursday, October 18th, the West European Studies Program along with the Global Health Initiative hosted a book discussion with Paul V. Dutton, Assistant Professor of History at Northern Arizona University, on his new book, Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France. Commentary was provided by Kimberly J. Morgan, Assistant Professor of Political Science and International Affairs at George Washington University

In his opening remarks, Dutton explained that one of his main goals in writing the book was to deconstruct many of the popular myths about socialized medicine. Quoting from Differential Diagnoses he stated "Americans often assume that all European health care systems are alike, something called "socialized medicine" under which the government, for good or ill, runs everything. Most do not understand that there are major differences among European countries in how they pay for and deliver medical care." He went on to emphasize that "the health care systems of France and the United States began the 20th century looking very much alike, then gradually moved in different directions while retaining a surprising number of common features and both countries would benefit from taking a careful look at their similarities and differences."

Dutton illustrated the fact that although the French system faces many challenges, the World Health Organization rated it the best in the world in 2001 because of its universal coverage, responsive healthcare providers, patient and provider freedoms, and the health and longevity of the country's population. The United States ranked 37. The French system is also not inexpensive. At $3,500 per capita it is one of the most costly in Europe, yet that is still far less than the $6,100 per person in the United States.

The author also explored the key periods in which the United States and France diverged in their perspectives on state involvement in health care. One such period of divergence was in 1915-1935, during which U.S. doctors, continued to reject a more comprehensive state-run health care system, resulting in an expansion of private insurance companies. Additionally, U.S. insurance companies fought hard against a more comprehensive, state managed health care system as well, often working in conjunction with U.S. doctors to kill reform efforts that would allow more state control. This was the case as Americans moved away from not-for-profit insurers soon after World War II with the establishment of companies such as Blue Cross Blue Shield. In contrast, many French doctors believed that expanding the role of the state health care system actually allowed for a greater personal freedom in their private practices.

Unlike their counterparts in the United States, French legislators overcame insurance industry resistance by permitting the nation's already existing insurers to administer its new healthcare funds. Private health insurers are also central to the system as supplemental insurers who cover patient expenses that are not paid for by Sécurité Sociale. Indeed, Dutton notes that nearly 90 percent of the French population possesses such coverage, making France home to a booming private health insurance market. Secondly, the French system strongly discourages the kind of experience rating that occurs in the United States, making it more difficult for insurers to deny coverage for preexisting conditions or to those who are not in good health. In fact, "in France, the sicker you are, the more coverage, care, and treatment you get."

Dutton drew similarities between both systems when describing how both systems utilize a public/private mix of financing, maintain the fee-for-service basis for physician reimbursement, and uphold ideals of physician practice autonomy and patient choice of doctor. In the case of the United States, when adding up federal, state, and local contributions 46% of health care costs are paid for. With the tax deductibility of insurance premiums the number rises to 50%. In France the government provides approximately 77% of the cost of health care.

Furthermore, today French reformers' number one priority is to move health insurance financing away from payroll and wage levies because they hamper employers' willingness to hire. Instead, France is turning toward broad taxes on earned and unearned income alike to pay for health care.

Dutton went on to state that, "American advocates of mandates on employers to provide health insurance should take note. The link between employment and health security is a historical artifact whose disadvantages now far outweigh its advantages." Economists estimate that between 25 and 45 percent of the U.S. labor force is now job-locked. That is, employees make career decisions based on their need to maintain affordable health coverage or avoid exclusion based on a preexisting condition.

Dutton concluded by also suggesting that the United States is almost inadvertently expanding coverage, but with little planning; at the same time, the French are adopting U.S. managed-care techniques in an attempt to keep down costs and improve efficiency in a system already offering universal coverage. He warned that the United States historical attachment to private insurers will eventually move the country towards a more National Health Service style of system by 2015 do to citizens not being able to afford the increasing cost.

Kimberly Morgan noted in her commentary that "this very thoughtful piece of comparative history approached the issue of health care in a unique way." Morgan specifically referenced Dutton's focus on how both the United States and France have tried to reconcile the ideas of liberty and equality, or freedom of choice with the role that the state should play in providing adequate health care coverage to its citizens.

Additionally, Morgan suggested that another important aspect of the comparison between the French and American health care systems was the importance of pluralism in both societies and how this plays into the increasing demand for health care resources in both nations. While both Great Britain Canada have used a more state dominated system managed from the top down, which has led to problems with patient wait times and backlogs, both the United States and France are struggling to reform their health care systems in large part due to decentralized interest groups in both countries, leading to the lack of a clear discussion that is not politicized.

Drafted by Matt Starling