As an low-income American, I’m one of the “lucky ones” in that not only do I have health insurance, I had it prior to the Affordable Care Act. I unexpectedly ended up with Medicaid in 2010 via a lottery system while living in the state of Oregon. After not having health insurance for a few years at that point and struggling with untreated chronic illnesses, I was more grateful that you could imagine.
And yet, due to the system being drastically underfunded, over the years I have learned the hard way more than once that having health insurance is not the same thing as having access to health care. When I moved to Portland in 2014, I found out that due to the large influx of new Medicaid patients after the passing of the ACA, that there were no MDs available anywhere in the city of Portland who were accepting Medicaid patients under the plan I was assigned to. Which means that while all my costs are still covered, any medical problem requiring a physician means that I have to go to an urgent care center or the emergency room.
Last month, five days before I was set to fly out to France for three months, I woke up in the middle of the night with severe stomach pains. I quickly reviewed my activities over the past few days in my head, which admittedly involved eating questionable food out of the fridge and accidentally swallowing water while I was in a public hot tub, and figured that I either had food poisoning or a bacterial bug from the hot tub water. I assumed that it would fade the next day, as it always has in the past, but two days later the pain had worsened and so I reluctantly dragged myself to urgent care, assuming that I’d be out a few hours later with a dose of antibiotics.
The urgent care center I went to in Portland is not a walk-in center – it requires one to make an appointment online. I foolishly assumed that making an appointment meant that I would be seen at the time that the appointment was for, especially as the confirmation email I received stressed that I needed to be there fifteen minutes early. So I made an appointment for 5pm, got there at 4:45, and proceeded to then wait two hours before I was even seen by the triage nurse.
And the triage nurse made it clear that it would not be a quick in and out. “Oh no,” she said, when I suggested that I just needed antibiotics. “All patients with stomach pains are re-routed to the ER.”
My heart sank as my anxiety spiked, internalizing both the realization that I would likely be there all night as well as the realization that there was a chance that it was actually something more serious. And my anxiety spiked further a few minutes later, after she took my blood pressure and temperature, when she opened up her drawer, tied a band around my upper arm, and told me to make a fist.
“Wait, what for?” I asked.
“I’m inserting an IV,” she answered.
“But why?” I asked, my heart pounding. To say that I’m not good with needles is an understatement. As someone with anemia and tiny veins, any puncture tends to cause me grief and complications.
“Its standard procedure,” she said. “They will probably need to give you fluids.”
“But can’t we wait until we know they need to do that first?”
“No,” she answered, and pricked my vein and inserted the catheter. She took some blood, capped the ends, and then sent me back to the waiting room, where I sat for another hour before the doctor came out.
The doctor ordered a CT scan, which I waited another hour for. The CT scan revealed something abnormal in my uterus, which was the last thing in the world that I wanted to hear five days before I was set to leave the country. The doctor then ordered a pelvic and vaginal ultrasound, which I waited another two hours for, as the ultrasound tech had left for the night and they needed to wait for the person on call to arrive.
Fast forward to a little past one in the morning, over eight hours after I had arrived. While I still had pains in my lower abdomen, at that point the IV in my arm was far more painful. Not only was it increasingly painful, but other than the initial blood draw and an injection of iodine contrast for the CT scan, they had yet to actually use it. Concerned about the pain, I sought out a nurse but at that moment the doctor came in.
“You had an ovarian cyst that burst,” he said to me.
Whaaaaaaaaa??? I thought to myself. “What does that mean?” I asked him.
“If the ovary was contorted, it would mean that you would need surgery. But in this case you are lucky and all looks fine. You’ll be in pain for a few more days, and I recommend a follow-up with a gynecologist.”
“How urgent is the follow-up?” I asked. “I’m leaving the country on Friday for three months.”
He looked down at my chart for a moment, then looked back up at me. “Honestly, with your insurance it may take you three months to get an appointment as it is. Will you have any kind of insurance over there?”
“I have emergency coverage,” I replied, and he seemed satisfied. A few minutes later, the nurse came in to remove the IV.
“Is it supposed to hurt like this?” I asked as she pulled it out. “Should I worry about anything?”
“Oh no, you’ll be fine,” she said dismissively.
* * * * *
I was discharged just past two in the morning, over nine hours after I had first come for my “appointment”. Over the next few days, the pains in my abdomen ceased as promised, but the spot on my arm where the IV had been started turning black and blue and aching in a way that I couldn’t brush off. By the time I was set to get on the plane, no trace of the abdominal pain remained, but my arm was starting to worry me.
I ignored it throughout the flight and for the first few days in France, but on the fourth night the combination of my pain and the anxiety around the possibility of complications got the better of me and I reluctantly turned to Google in search of a doctor, terrified of what it would cost me as a non-citizen.
I quickly went from terrified to shocked and angry, not at the French system but at the American system.
* * * * *
To talk about “socialized health care” in itself without qualifiers is a bit disingenuous, as different systems operate in very different ways. And when Americans talk about socialized health care, more often than not derisively, not only are they speaking out of utter ignorance in the big picture, but the vast majority of the time they are clueless as to the distinctions between different systems. Their view on socialized health care is usually based on a personal anecdote they heard from a friend or acquaintance about waiting times in the U.K. or Canada. They will then go on about how the American system is better because of “choice” and the lack of waiting lists, completely ignoring the fact that an estimated 45,000 Americans die ever year due to lack of access to health care, having absolutely no “choice” in the matter at all.
The NHS in the United Kingdom is one form of socialized health care, generally known as the “Beveridge Model” as a tribute to the social reformer who designed the system. Under this single-payer system, most clinics and hospitals are owned by the government, the entire system is paid for by the government through taxation, and every permanent resident of the UK has access to the system free of charge. As both payer and provider, the government has control over pricing and treatments, which other than waiting lists tends to be the primary complaint of Americans who criticize this system. And while it isn’t perfect, polls and surveys regularly show that a majority of UK citizens approve of and are satisfied with their health care system. The Beveridge model has been replicated in many other countries, including Spain, Cuba, New Zealand, and Hong Kong.
Canada’s system is similar to the Beveridge model, except that providers are private entities, not government employees, and most hospitals and clinics are privately owned. While still providing much better coverage and care to its citizens overall than the American system, the Canadian system is known for long waiting lists for certain procedures in many areas, and more often than not it is stories of long waits in Canada that Americans hear of and use as an excuse to dismiss all forms of socialized health care as “un-American”.
The French system on the other hand, works on a different model than either the British or Canadian systems, known as the “Bismarck model” after conservative German chancellor Otto von Bismarck who pioneered the model in Germany in the late 1800s. The Bismarck model differs from the Beveridge model in that it uses an insurance model and doctors and hospitals are are usually private. The Bismarck system uses a multi-payer model – all permanent residents receive insurance from the state, which covers a majority of any given procedure, which can then be supplemented by secondary private insurance that covers the rest. But unlike private insurance in the United States, insurance companies under the Bismarck model are mandated to be non-profit. The Bismarck model is currently used throughout much of Europe – not only in France, but in Germany, Belgium, Switzerland, and the Netherlands. The Bismarck model is also used in Japan. A report put out by the WHO in the year 2000 ranked the French system as the overall best health care system in the world.
* * * * *
I knew all of this going in, but what I didn’t know was how accessible the system was to non-residents. It took me only a moment on Google to learn that for most doctors who work within the French social security system, an appointment is only 23€ regardless of one’s residency status. For permanent residents, their social security covers 70% of that fee, and if they have additional insurance (mutuelle) it covers the rest. But as an American, who in the past has paid $50 copays with private insurance to see a general practitioner, the fact that I had no insurance and would have to pay the full 23€ did not bother me in the least.
And waiting lists? Nope. A few minutes on Doctolib and I found a physician a few kilometers away from where I was staying, who had appointments available the next day. The website even let me know which doctors spoke other languages. I filled in my info and made an appointment for the next morning.
* * * * *
The office was simple and sparce. A small waiting room with a few chairs and a table from IKEA that had a few magazines on it. No television, no receptionist, no nurse, no billing specialist. From what I can tell, the medical billing industry, which is a 6.3 billion dollar industry in the United States, is non-existent in France. I wanted for only five minutes before the door opened, the doctor said goodbye to his previous patient, and waved me in.
His English was limited, as is my French, but between the words we knew and some help from Google Translate, we managed just fine. He asked me about the experience that led to my bruised arm, giving me a rather shocked look when I told him about the unnecessary IV in my arm for eight hours, and after a few minutes of poking at it told me that he thought it would be okay, that he was going to prescribe me a cream to speed the healing, and that they should have used a child-sized catheter. He then walked over to his desk, steps away from his examination chair, where his computer and credit card machine was. He printed me out a prescription form for the cream, filled out a receipt for the visit by hand, explained to me where the nearest pharmacy was, and rung up my card. I was in and out in less than fifteen minutes.
I then walked over to the pharmacy. Similarly to the doctor’s office, it was obvious that there were no cashiers, no assistants, only the pharmacist herself. I handed her the slip, again bracing for the price, and asked what turned out to be a foolish question.
“Quand devrais-je revenir?” (When should I come back?)
The pharmacist looked at me very strangely. “Attendez un moment, s’il vous plaît,” she said, and walked over to a drawer. She opened it, pulled out a tube, and walked back to the register. I had my prescription in less than fifteen seconds, as opposed to the standard hour or two that one waits in the United States.
“Carte vitale?” she said, asking me for my social security card.
“Non, je ne suis pas citoyen,” I answered. She typed something into her computer, took my form from the doctor, and stamped it. I reached for the 50€ bill in my pocket, hoping it was enough.
“2,61€”, she said. I thought I misheard her at first. I repeated the price back to her and she nodded in agreement. I handed her a 5€ bill and hoped she wouldn’t notice my visible shaking as she handed me the change.
After I left the pharmacy, I pulled out my phone and Googled the name of the medication, and then proceeded to nearly shit my pants when I saw that in the United States, the price of the cream without insurance was nearly $2500.00.
* * * * *
“Yeah, but they pay outrageous taxes over there…”
Later that day, when I posted a much shorter version of this story on Facebook, the pushback from some conservative-minded folks was fast and fierce. It’s a claim that I’ve heard many times before, and it simply does not stand up to facts.
Current American tax brackets:
Current French tax brackets:
2013 French tax brackets (included because it shows higher incomes)
While the tax rates in France are higher for the upper brackets, they are significantly lower for lower-income folks. And when you factor in what Americans pay for health insurance, and the costs that they so often still incur despite having health insurance, paying slightly more for the kind of system that the French have seems quite sensible. And not only do those slightly higher taxes provide universal health care coverage, it also provides generous maternity leave and free university education among other things.
* * * * *
One thing that I first noticed last summer, and I’m noticing again here now in France in the midst of the presidential elections, is that health care in France is not a political wedge issue. Unlike in the United States, where health care has been a dividing issue for decades now, its not even mentioned in the rhetoric around the French elections. French citizens, whether left or right, pretty much all support universal health care, as do the politicians that represent them. Nowhere, not even amongst the far-right, have I heard any of the kind of rhetoric that’s commonplace in the United States. The idea that health care should be a right that’s granted to all citizens regardless of income level is not the least bit controversial here, nor is it controversial in the vast majority of the developed world. Pretty much everyone I’ve spoken to here about health care, regardless of their political leanings, are completely baffled as to why Americans do not support universal health care.
Only in the United States does a significant portion of citizens and politicians alike think that its acceptable that thousands of people suffer and die due to the lack of ability to afford and access health care. And only in the United States does a significant portion of the population tie that belief to the idea of “freedom” and national pride.
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Further Information on the French health care system: