By Pascal-Emmanuel Gobry
Thursday, May 16, 2019
One of Charles de Gaulle’s most notorious moments of
public wit came when he was asked at a press conference whether “Europe” wasn’t
the solution to France’s problems. After a long defense of his policies, he
exclaimed: “Of course, people can jump up and down on their chairs like mountain
goats and shout ‘Europe! Europe! Europe!’ but it means nothing and leads
nowhere.” It seems that when it comes to health-care reform in the U.S.,
progressives often think it’s enough to jump up and down like mountain goats
and shout “France! France! France!” But it’s not. I am proudly French, and I
have seen the problems of socialism in my nation firsthand.
Let’s get the obvious out of the way first: Yes, the
French health-care system is, at the moment, almost as amazing as they say.
Taking my frighteningly sick daughter to Necker, the main children’s hospital
in Paris, made me proud to be a French taxpayer. Not only was the building
gleaming and everything in it high-tech, but the staff was first-class,
efficient, and, above all, kind, a world away from bureaucratic cliché. When,
on my way out, after my daughter had recovered, I asked whether I had to pay
for anything, the staff looked at me as if I’d just flown in from Mars.
Nonetheless, the French system offers virtually no
lessons applicable to the United States.
Progressives either dislike private insurance or want to
ban it outright; the French system relies on private insurance. Health-care
wonks left and right agree that the biggest problem of the U.S. system is that
it is employer-based. French health care? Also employer-based.
Since long-term and so-called lifestyle diseases such as
obesity, diabetes, and heart diseases currently pose the biggest threats to
public health, progressive health-care wonks are obsessed with preventive care.
What’s one of the few areas where French health care lags behind the rest of
the world? Preventive care.
Another progressive villain is prescription drugs, and
France is a notorious over-consumer of them. While progressives are rightly
enthralled with the idea of “evidence-based medicine” (while failing to realize
that mandating it is sure to bring dysfunction), the French government has
found a, let’s say, ingenious way to get French people to ingest fewer drugs:
It promotes the notorious fraud of homeopathy and, in some cases, even pays for
it. The French are also inexplicably obsessed with psychoanalysis, to the point
that French mental-health care is essentially stuck in the 1930s. In the name
of environmentalism France has long banned genetically modified organisms that
science says are harmless for humans and good for the environment, and the
government recently bowed to public pressure and passed a partial ban of
glyphosate, a herbicide that activists say causes cancer even though scientific
studies have found no such link. (Activists say these results are due to a
conspiracy; 80 percent of French people support a ban.)
Progressives advocate information technology as a way to
make the U.S. health-care system more efficient (again: excellent idea in the
abstract, a disaster if you do it via central planning); France is a health-IT
laggard.
Progressives routinely point to inequalities in life
expectancy between the richest and poorest Americans, often implying that
imitating policies such as France’s would reduce the difference. The Washington Post called the American
life-expectancy gap “stunning,” and Vox
blamed it on the Trump tax cuts — really. Such claims imply that America’s
socioeconomic system is notably bad when it comes to health and death. They don’t
say it outright, though, because, compared with other OECD countries, the
United States is in the middle of the pack for health inequality — right where
France is.
So if French health care is so similar to health care in
the U.S., how does it manage to have such different outcomes? The answer is
that France, with its tradition of state-directed authoritarianism, is able to
achieve something that is politically radioactive in the U.S.: severe cost
control. France has the lowest doctor pay, relative to average income, in the
OECD. A young general practitioner in France made 69,900 euros on average in
2011 (roughly $97,200 at the time), according to the French National Statistics
Office. Currently, nurses make 21,840 euros (around $24,300) on average. Despite
having to hold the equivalent of a bachelor’s degree, French nurses make 5
percent less than the average income, according to OECD figures.
Which is a natural response to the financial stress on
the system. While the French health-care system is presently good, it is also,
well, dying. It has its own dedicated tax revenues and spending streams — every
year, the French parliament votes on not one budget but two: one for general
government and one for health care. The system has been running a deficit every
year since 2002. France spends around 11 percent of its GDP on health care
every year, which is certainly less than that crazy outlier America but still
very high compared with the rest of the OECD. Government spending is already at
around 56 percent of GDP, and given EU-imposed budget rules there is not much
room to spend more — even as the wave of Baby Boomers is retiring.
Which doesn’t leave many options besides squeezing more
hours out of already-underpaid workers and cutting benefits. While nurses’
salaries stagnate, their working hours keep increasing. According to a survey
by the National Order of Nurses, 63 percent of nurses show at least one symptom
associated with occupational burnout, and 25 percent have sought psychiatric
help as a result of work-related stress. In the health-care utopia of France,
22 percent of nurses polled say they are seriously considering getting into a
different line of work.
And there aren’t many ways left of decreasing costs.
Rural hospitals have been merged, creating so-called medical deserts — large
areas with no doctors. In 2017, three years’ worth of incident logs from the
central teaching hospital in Toulouse, a trove of 26,000 documents, was leaked
to the media. Toulouse is a large city known for its picturesque center, nearly
year-round Mediterranean sunshine, good universities, a winning rugby team, and
being one of the hubs of France’s vaunted aerospace industry — all Airbus jets
go through final assembly in Toulouse. If you were looking for a place to represent
the best of French health care, the teaching hospital in Toulouse would be a
top candidate. And yet those incident logs tell a different story.
In a French hospital, each time something unexpected
happens, an incident log is filled out. While most of the 26,000 log entries
represent the normal imperfections that are found in any organization, “more
than a thousand are a sign of poor . . . conditions . . . that can threaten
patients’ lives,” said Sylvain Morvan, editor of the local news site Mediacités, which unearthed the
documents. Requests to fill holes in the floor received no response for two
years. Overweight handicapped patients were left to lie in bed indefinitely for
lack of suitable equipment to help them up, leading to further health troubles
and depression. In one log, a nurse wrote, “My team is exhausted, physically
and psychologically. . . . We feel like we are not doing our jobs well and
endangering patients’ lives.”
There’s another way in which the French health-care
system stands out: It has the lowest share of out-of-pocket spending in the
OECD. There’s hardly anyone who doesn’t think that has to change; in the
immortal words of Barack Obama, “it’s arithmetic.” Perhaps, say hopeful
center-left reformers, more cost-sharing will lead to more competition and
innovation, which sounds awfully . . . conservative. The French health-care
system has turned out to be a good illustration of Margaret Thatcher’s quip
that the problem with socialist governments is that sooner or later, “they
always run out of other people’s money.”
With demography putting relentless pressure on costs even
as budget constraints mean spending must go down, I always hear the same story
from nurses, doctors, and administrators I interview: Yes, right now we are
doing okay, but the system will collapse sooner or later.
And that is a story you can tell about the French welfare
state in general. As Democratic presidential candidates contemplate proposals
such as universal day care and free college tuition, they would again do well
to look at France — actual France, not the fantasy of progressive propaganda.
American writers often laud the supposedly wonderful
French public day-care centers. In 2013, Pamela Druckerman, the author of Bringing Up Bébé, the book that
identified a supposedly superior French style of parenting (remember that?),
wrote a typical op-ed in the New York
Times urging America to “catch up with France on day care.” As someone who
lives in France, has a young child, and has many friends with children, I’ve
certainly heard lots of very nice things about French day-care centers, known
as “crèches.” But I’ve yet to meet anyone who has experienced them firsthand.
As I wrote back in 2013: “When my wife got pregnant, we duly went to the local
crèche office to apply for a spot (well over a year in advance!). When we asked
how likely we were to get one, the nice lady simply laughed. She could put us
on the waitlist, she said, but that almost certainly wouldn’t make a
difference.”
The French government seems to have given up on trying to
make up for the shortfall. Back in 2012, François Hollande was elected
president partly on a promise to create tens of thousands of new spots in
crèches, but he essentially abandoned that promise on Day One. There are now
regular news stories about corruption in the awarding of crèche spots. All of
this was predictable: Public provision of important goods leads to rationing and
thence corruption.
Pro-family policy has been one of the most ancient and
cross-ideological commitments in French politics. France’s war defeat by
Germany in 1870 was seen as the result of Germany’s higher fertility rate, and
raising fertility was thereafter considered necessary to win the eventual
rematch. Pro-family policy was embraced by the left-wing Popular Front in the
1930s and the Vichy regime in the 1940s, and in the post-war cross-party
settlement it was embraced as one of the three “pillars” of France’s new
welfare state, alongside socialized health-care coverage and redistribution.
This commitment has changed only recently. Obediently
following German instructions to reduce the deficit, François Hollande passed
unprecedented cuts in family benefits, which now nobody talks about reversing,
and the Macron administration occasionally floats proposals for further cuts as
a way to balance the budget — to a silence that is striking, given French
tradition. Everyone knows why: There’s no money anymore.
As for college, far be it from me even to indirectly
endorse the insane American higher-education bubble, but every time I cross an
American college campus I feel a pang of envy. France does have “free college,”
of a sort. Its higher-education system is a massively complex tangle of various
types of institutions awarding various types of credentials to various types of
students. Any high-school graduate (which means, in practice, almost every
18-year-old) is entitled to a spot at a free public university — which makes it
odd that private higher education in France is thriving, with close to 20
percent of students going that route. Between 1998 and 2016, private
higher-education enrollment grew by 88 percent, as opposed to 14 percent for
public higher education.
The explanation cannot be prestige, as might be the case
among America’s elite universities, since France’s most prestigious schools are
all public. Nor are private institutions massively subsidized — government
funding represents a modest 7 percent of private higher-education institutions’
budgets on average.
The answer becomes obvious when you actually set foot in
one of those public universities. My top-ranked law school’s library, for
instance, on top of being crumbling and having Wi-Fi that didn’t work most days
and only a handful of computer terminals, had a glass wall oriented so that
sunlight hit it directly. That wall, combined with a lack of air conditioning
and ventilation, turned the library into a locker-room-scented sauna — especially
in the spring, which is exam season — with predictable consequences for library
attendance.
Then there’s the matter of elitism. The world of public
universities and professional schools exists apart from the schools that give
you a ticket to the French elite. These, the grandes écoles (literally, great schools), are where upper-crust
parents want to send their children. Unlike public universities, which are open
to all high-school graduates, these tiny schools can be entered only via brutal
competitive examinations that require two to three years of post-secondary
studies. Students who want a shot at the top universities must typically spend
70 to 80 hours a week cramming in an intensely competitive atmosphere, with
predictable effects; suicides at the top prep schools are a fact of life,
accepted by all.
So it’s no wonder that even though there are free public
prep schools, students from unprivileged backgrounds cannot compete in them.
It’s impossible to study 70 hours a week if you also have a long commute, which
would be the case for anyone who lives outside the expensive city centers where
the best prep schools are. Free universities turn out to be not so much a
commitment to social equality as a handout to the plebs so that they don’t
demand access to the actual paths to elite status.
There is a recurring theme. Somehow, every supposedly
progressive French policy turns out to have the same effect: to cement the
power of the upper middle class and sap upward mobility. Labor-market
regulation is great for grande école
graduates; it’s not so great for the lower-skilled, who must make do with
temporary jobs since employers are reluctant to be locked into expensive labor
contracts. Housing-market regulations, supposed to protect tenants from abusive
landlords, artificially prop up housing prices and subsidize elderly rentiers
even as they make it hard for the underprivileged to find housing. And so on
down a very long list.
It is difficult to see all this as a coincidence, given
that the people who make the rules are those who benefit. Since the election of
Emmanuel Macron, more and more observers have become aware that virtually all
of France’s leadership roles are held by people who went to the same schools
and share the same background. Macron describes himself as a progressive, and
people like him believe that, owing to their superior education, they have the
right to order society for the benefit of everyone. Given the results — low
growth, mass unemployment, social strife, and a general mood of pessimism (80
percent of French people believe their children will be worse off than they,
the highest rate in Europe) — they might want to rethink their idea of
progress.
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