A few days after the New Year, we were hit with a freezing cold front on the French Riviera. It having been twelve years since I lived in Finland and last had to deal with ice on a day-to-day basis, I had essentially forgotten about the slippery phenomenon.

That is, until my foot slid on the sidewalk and I thought to myself, “these soles are really wearing out,” put down my second boot, thinking it would stabilize me, then, as both slipped out from under me, I promptly found myself seated on my now-freezing rear end. “What??” I put my hand on the sidewalk. What should have been gummy, rough asphalt was instead icy smooth. I ran my hand over it inquisitively, and finally the memory returned: “oh, ice! What?! Here?!”

I picked myself up and paid more attention while I finished walking from the bus station to our offices. Fifteen minutes after settling in at my desk, my lower back began to ache. I soon realized I wouldn’t make it through the day without painkillers, and so called up a doctor. I was able to get an appointment an hour later. By then I was nearly unable to walk from the pain, much less stay seated for very long. The doctor prescribed x-rays of my lower back, an anti-inflammatory (ketoprofen) and painkiller (paracetamol), and sent me home for two days of rest. Since the accident had been on my way to work, our office assistant filled out an accident de travail form, which is the first time I’d ever seen one. It’s roughly equivalent to workers’ compensation in the US.

It turns out that having an accident de travail makes everything even simpler than health care already is in France. I don’t have to pay for anything that is prescribed as a result of my accident. Not even the usually-mandatory base fees that, otherwise, would later be reimbursed. As a result, the five x-rays of my back (only two are shown there) were free, and my regular physician prescribed 15 physical therapy sessions, which are also entirely free. My spine, sacrum and coccyx are fine; the doctor who did my x-rays even pointed out that I have “particularly well-spaced vertebrae”. Way to go, vertebrae. The muscles, however, are a different story; it’s only today that I’ve been able to go without using much pain medication.

I was able to find a great physical therapist with offices five minutes from where I work. Few things are better than a deep, full-back massage right after a long day.

I’ve had a gurgly stomach and painful abdominal cramps since Monday. Since my stomach is generally able to withstand pretty much anything I throw at it (the only exceptions being gluten and casein), I figured it would get better, but instead it’s worsened gradually. I could barely sleep last night for the pain, and was unable to move due to cramping after eating breakfast.

So, this morning I emailed our offices to let them know I was ill, then called my general practitioner at 9:20 am. My regular doctor wasn’t available until tomorrow morning, so I asked if another was. (I’m grateful to have found an office with three doctors, all of whom are good, upon my arrival in Nice nine years ago.) Another was indeed able to take me at 10 am — 40 minutes later. I took a quick shower, then walked to the doctors’ office, which takes 10 minutes.

I waited a half an hour, reading a couple issues of L’Observateur. Then the doctor examined me, diagnosing a bad case of indigestion, and prescribed me a proton pump inhibitor to take for a month (pantoprazole for anyone curious), an antispasmodic, and rest. He gave me an arrêt maladie (permission for work absence due to illness) for today, ran my carte vitale through his reader, and I wrote him a check for 22 euros, all of which will be reimbursed by the sécu and my supplementary insurance.

Then I went to a nearby pharmacy to fill the prescriptions. I presented my carte vitale; they already have my supplementary insurance on file. The pharmacist replaced the branded medications with generics, wrote the correspondences on the boxes so I’d know which was which, put them in a bag, and said “bonne journée, au revoir !” The medications are fully reimbursed, so I didn’t have to pay anything.

I was home by 11 am. It took less than two hours for me to make a doctor’s appointment, take a shower, go to the appointment, get diagnosed, pick up medication, and walk home. Total cost, once the 22 euros are reimbursed (tomorrow): Zero. Although I will admit the walk wasn’t much fun considering how tired and weak I am, but still, it was free monetarily speaking. It’s taking all the self-restraint I have not to make a scathing remark comparing this French experience to the US. And in my ten years in France, this experience is the norm — I usually get an appointment on the same day, within a couple hours of calling.

Related post explaining more about France’s sécu, the carte vitale, supplementary insurance, and why I paid at the doctor but not the pharmacy: Health care in France – Basics

In my previous post on French health care, I went over the basics of how things are done here. In this post I’ll compare some statistics, citing Canada and the UK as well since those two countries have often been the focus of recent debate in the US.

The last time the World Health Organisation (WHO) ranked world health systems was in 2000 — they no longer produce rankings since it’s so complex a task. Here are how the four countries fared:
1. France
18. United Kingdom
30. Canada
37. United States
Countries such as Colombia, Saudi Arabia, Morocco and Chile also ranked higher than the US.

Life expectancy has become part of the debate in the US currently. These rankings were taken from the list of countries by life expectancy:
8. France, with an overall life expectancy of 80.87 years
14. Canada, overall life expectancy 80.34 years
37. United Kingdom, overall life expectancy 78.7 years
45. United States, overall life expectancy 78.06 years
The French live nearly 3 years longer than Americans, on average.

Another key issue is pregnancy and childbirth. Here are a few stats taken from Wikipedia’s list of countries by infant mortality rate. The first number is the infant mortality rate per 1,000 live births, and the second is the under-five mortality rate per 1,000 live births:
Iceland: 2.9 and 3.9 (they have the best numbers)
France: 4.2 and 5.2
Canada and the UK: 4.8 and 6.0
USA: 6.3 and 7.8

In France, pregnant women have 3 sonograms and blood tests (one per trimester), with a three-hour blood test around the 4-month mark. All covered at 100%. Anything beyond that’s deemed necessary is also covered 100%. Mothers-to-be get 6 weeks of paid vacation legal minimum before their birth date — it can be extended, for instance if the pregnant woman lives more than an hour’s commute from her offices. They then get 10 weeks after giving birth. Fathers get 11 days of paid vacation (18 days if they’re father to twins or more). Postpartum exams are covered. Parents are given allocations familiales depending on their need; all get a basic “starter” minimum of several hundred euros. There are also allocations to help cover childcare if/when the mother returns to work. Mothers have the option of working 4 days a week instead of 5; fathers can now do this too (but only one member of the couple can do this, and there is a sort of “salary cut” in that a few — less than 10 — vacation days are removed if they choose the “4/5 work week” as it’s called).

All this and per capita, in France we pay half what Americans do: Health Care Spending in the United States and OECD Countries (2007).

From another scientific study, Americans Spend More on Health Care But Are Not Healthier:

The study is the first to use a universal set of standards to compare the quality of health care in the five countries surveyed. The researchers found that no country scored the best or worst overall and that each country was the best and worst in at least one area. The study is published in the May/June 2004 issue of the journal Health Affairs.

Peter S. Hussey, lead author of the study and a doctoral candidate in the Department of Health Policy and Management, said, ”It is well known that the United States spends much more on health care per capita than other countries, and it is commonly assumed that we have the best health care system in the world. However, the results of our study show that the United States performs better than other countries in only a few areas, while performing worse in others. This raises the question of what Americans receive for all of the money devoted to health care.”

Overview
France has a public health system called “Sécurité Sociale”, also known as “Assurance Maladie”. It has a standardized, automatic, electronic system for processing bills and reimbursements. Every French citizen enrolled in “sécu”, as it’s called for short, receives a green card with a microchip, called “carte vitale“. The carte vitale contains only insurance-related information; no medical records are stored on it.

It is also illegal to publicly advertise pharmaceutical products and medical services in France. Quote from the linked article: “Direct-to-consumer advertising is forbidden in France for reimbursed and prescription-only drugs, with the exception of vaccines and products used [to help quit smoking].” Pharmacists, doctors, hospitals, etc. can only have office signs, for instance, and there are no TV advertisements for prescription medication.

Sécu covers a range of percentages, up to 70%, of basic care: general practitioner visits, opthalmologists, dentists, prescriptions, and so forth. Emergency care is always 100% covered. Prescription medication for chronic conditions is also always covered at 100%.

To cover the remaining percentage of basic care, you can choose a private health insurer. In France, those known as “mutuelles” (mutuals) are required to be non-profit, and also cannot advertise. They usually cover 100% of the remainder, with some exceptions for optical and dentistry. I happen to have one that covers 100% of everything, optical and dentistry included. For optical and dentistry there are reasonable limits, which means I can get “only” one free pair of prescription eyeglasses per year, for example, and there is an upper limit to the frames’ price.

Going to the doctor, the pharmacy and the ER
For regular doctor visits, when you go to the doctor, you show your carte vitale, which is put in a special reader. Since doctors can set their own rates — the government does not control them, it only sets a maximum amount beyond which it won’t reimburse — you pay for the appointment at the end. Your payment is reimbursed by the sécu at the going percentage, and the sécu transmits the details to your supplemental insurer, who then reimburses the rest per your policy — all electronically and automatically, direct to your bank account if/when you give your account details. (As a tangent, bank accounts are highly secure in France, and so it’s quite safe to give out a “deposit permission”. No one can take money from an account if all they have is the deposit info.)

When you go to a pharmacy, you again show your carte vitale. If you’ve been to the pharmacy before and they have your supplemental insurance information on record, you don’t need to show it again since they link it with your carte vitale. Since prescription medication prices are set by the government, if your supplemental insurance covers them at 100% beyond sécu rates, you won’t have to pay anything. At all. It’s processed automatically. (This is a VERY weird sensation when you’re an American and used to paying — 10 years later and I’m still not used to being given a bag of medication and just walking out.)

For emergency care, an example: three years ago I fell off my mountain bike and nearly broke my ankle. I had to call an emergency number. The firemen — they’re also trained EMTs here and so answer medical emergencies as well as fires — took me to the closest hospital. I was evaluated immediately on arrival. Only once they saw that I was at no immediate risk did the hospital ask me for my carte vitale. The firemen/EMTs hadn’t asked me for anything; they gave the hospital whatever information they needed. I had some X-rays and the wound was cleaned, then I was told to go to my general practitioner for follow-up, and I was sent home.

That was it. No bill. I was given copies of my X-rays and the doctors’ evaluations to show my GP, but nothing more.

My GP then prescribed physical therapy, an ankle brace, and pain medication. All of it was covered at 100%, and the only thing I had to “pay” for was the doctor’s appointment — as described earlier, it was automatically reimbursed 100%.

Paperwork and prices
To show how basic care is documented, I took a photo of my latest sécu and private health insurance reimbursement statements, along with a shot of my carte vitale so you can see what it’s like.

For information, my GP charges 22 euros. A specialist I go to regularly for my preexisting condition (covered 100%, because there’s no concept of “preexisting condition” in France) charges 45 euros. A packet of ten 500mg aspirin costs about 3 euros over-the-counter; it’s free when prescribed. A three-month supply of the Pill costs 27 euros. (The Pill is one of the only prescription medications not to be covered by sécu, so we do pay out of pocket for that — it’s the only prescription med I’ve ever had to pay for.) I don’t know what ER/hospital stays are charged because mine have always been entirely covered.

My supplemental health insurance costs me 20 euros a month. The national health insurance is paid as part of employer taxes; in my case, my employer pays 320 euros a month. That amount is paid directly to national health care, my salary is not affected. Everyone, not just employees, enrolled in sécu is covered, and as you can see from my case, you don’t have to be a French citizen in order to be able to enroll — you just have to work or study in France.

Conclusion
The only thing I have to worry about is having my carte vitale on me. If I don’t have it, it doesn’t matter, I’ll still be covered — I’ve been able to return to a doctor/laboratory/hospital (yeah, I’ve been around) with my card after minor emergencies when I hadn’t had my card on me at the time, no questions asked. I don’t have to worry how much anything costs. I don’t have to avoid doing sports out of the fear I might hurt myself and lose insurance coverage. I don’t have to worry about being able to afford medication. In the 10 years I’ve been in France, my health has honestly become something I only ever think about when I’m ill or injured, and even then all I need to do is call my doctor. I’ve always been able to get an appointment the same day.