In a comment to another post (EHIC/CEAM Play the right card!), MikeP voices scepticism about my suggestion in the title of this post.

I maintain that French health cover is cheap for the price. I have no doubts whatever about this -- which is a total ideological about turn for me and the conclusion of many years observation which have proved my initial opinion very misguided. As a self-employed person, I calculate the pros and cons every time I seethe while writing that costly cheque for "social charges". So I looked into the whole story.

We are talking about real comparisons between systems here, not absolutes. In absolute terms, all countries' systems are outrageously faulty, albeit in different ways.

Let's look at the facts but first presume that we are looking at roughly equivalent situations and that these situations are "average" - as far as that is possible. If we start to look at exceptional circumstances we will always find winners and losers and we could debate this forever. Abusers of the system are an unfortunate part of life everywhere. France is no worse than anywhere else for that.

So what is an "average" person? Putting exceptional cases aside, I presume for the sake of example that an "average" person has a spouse and 2 children and earns an "average" income. He will work for an average number of years, retire at an average age and have the occasional illness or accident, none of them especially serious. I believe this to be 75% (or so) of people in any country you could name.

Compared to other systems the French system is indeed cheaper and better for the vast majority of "average" people and here is why.

1/
MikeP says "I've worked in France as an employee, the SS has cost me 22% of my salary." He indeed pays 22% during his working life for what he admits is usually good care. But let's not forget that while he is growing up (presuming he grew up in France which is the case of 90% of Sécu beneficiaries) and when he retires (and these days retirement can be almost as long as employment) he will pay NOTHING into the French system and still get the same level of care. That changes everything when you compare the cost to other systems of equivalent quality.

In the anglo-saxon system, a high quality of care requires lifelong payment into a PRIVATE system and becomes impossible for many people just at the time of life when their income has seriously decreased as it usually does after retirement. At the same time, their health problems are likely to increase. Proper care means paying expensive private insurance at a time when one can least afford it.

And private medical insurance is more expensive as a family (even only a 1 or 2 child family) grows.

Neither of these perfectly normal cases apply with the Sécu.

So the fact is this:  presuming an average life span of 80 years where someone works for 40 years and is in education or retired for 40 years, that 22% becomes 11% of lifelong income for cover over his entire lifetime and covers his children while they are growing up and himself and (in some cases) his spouse when they retire. In fact, technically it's less than 11% because during retirement most people do have an income (their pension) upon which they pay very little (only the CSG) to the Sécu. A case could easily be made for lifelong French health care costing well under 8% of a persons lifelong income (salary plus pension) -- but to save complex calculations let's settle on the unrealistically higher figure of 11%. That's the maximum in almost every case.

Life long quality health care for less than 11% of one's lifetime income. That's remarkably cheap!

In the anglo-saxon system NHS/Medicare becomes free from retirement but French quality care still has to be paid for if you want it in the UK or the US system. If you want rubbish care in other systems, it's free during retirement but it does reduce your chances of having a long and healthy old age. This explains today's proposition that £12,000 be taken from each UK estate after death to pay for NHS care during retirement. But it will still be variable quality state care, and nothing like the quality of private care in the UK or public care in France.

2/
That 11% doesn't only cover "care" as such. It finances the building of hospitals, public ambulances (SAMU), IRM machines, medical laboratories, research, operating theatres, doctors and nurses training, and many other things. Not the least of which is the right not to suffer the indignity of dirty mixed public wards, or in many cases, any wards at all. French hospitals usually offer private rooms or shared with 1 other patient.

For his 11% the French insuree and his family don't normally endure waiting times for diagnosis and care as they would in "cheaper" systems. And how cheap is cheap when you're talking about rapid life saving diagnosis of a child's illness?

That 11% does not however cover the posh country estates and limousines of so many British and American doctors and clinic owners. I wouldn't know how to compare the cost of the "army of state employees, quangos, and organisations" (and they certainly do exist) with the Harley Street crowd of consultants largely benefiting from public as well as private purses. But I'd hazard a guess that one is no more expensive than the other. It is certain that both are abusive to some extent but they are unfortunate corollaries of each system, not its reason for being.

3/
It's not only MikeP and his fellow insurees who is covered by his payment of 11% (or 7.5%?) of his lifetime income. His children are too while in education as would be his spouse if she were not working (but a stay-at-home spouse is the exception these days, so both spouses usually do pay as long as they are working). A private system would want extra payment for each non-employed dependent.

4/
The Sécu is heavily in deficit and is subsidised. So is the NHS and American Medicare -- except that for "our" deficit we get better and faster care than "they" do. The irony is that the American free market economy is the most indebted in the history of the planet and that debt (deficit) is held largely by an undemocratic communist country - China. If China pulls the plug, Americans lose their health care system and just about everything else. Personally I wouldn't want to put my economic and medical future into the hands of the Commie Red Giant.

5/
MikeP and the rest of us are "subsidising people who have large families". And single people are subsidising our "normal" families. In fact everyone is subsidising someone else in one way or another, and that is so in every system. The biggest disparity is that the young and healthy subsidise the elderly sick and injured everywhere.  France is certainly no different. It's a moot point and one of principle only. We do subsidise those large families but I don't think they are the norm and I don't think they are so many as to have enormous practical impact from a financial point of view.

The French system is much more cost effective than most in this field. Because in France we are NOT subsidising health care for millions of people who have never contributed to the system.

Why do all those Eastern Europeans flock to Sangatte looking for a way into Britain? Because France doesn't give them social benefits and health care subsidised by the French taxpayer the way Britain does from the second they manage to cross the Channel. And who is paying for the health care of several million "wetbacks" who have crossed into the US from Mexico to work illegally?. The American taxpayer that's who. Puts those large immigrant families who abuse the French system into an interesting comparative perspective doesn't it? Rachid and Amar might be abusers but they're rank amateurs at it compared to Pedro and Vaclav.

I like how the French system is without mercy for the flagrantly undeserving. If you haven't paid in, you don't get covered. Makes perfect sense. Other countries should adopt this form of hard core capitalism where their health care systems are concerned.

6/
MikeP says we are all subsidising "an army of state employees, quangos, and organisations". He is right but how is that different from any other system? The public sector is every bit as numerous (about 1/4 of the population) -- albeit less bureaucratic -- in the UK and Ireland as in France. Equally as incompetent and inefficient but a lot more polite and humane than French civil servants tend to be. Everything public service workers do (including becoming ill) is paid for by taxes and social charges in every country, France included.

7/
There is a very important "insurance" aspect to French style health cover. You are covered no matter what -- including serious illness or accident requiring expensive life long care, birth defects, a child born with a mental or physical disability, mental illness (psychiatric care is not covered by most private schemes in the UK or the US), genetic disorders, etc. Pre-existing and birth conditions are covered at a high level for all, not just the well-off or the lucky.

Try getting an American HMO or a British private insurer to accept someone with a serious pre-existing condition like diabetes, Downs Syndrome, a physical disability or a genetic neurological disorder. These are conditions that are not the fault of the patient. So do we want to share the burden of their bad luck (which could have happened just as easily to us or our children), or don't we? Someone in good health and who does not intend to be a parent will say no to it. The rest of us would probably want that insurance... or at least I would. Especially as it's so cheap when calculated over my lifetime.

People who never have a car accident and always lock their car are "subsidising" the insurance of people who suffer from accident or theft. Sure, there are abusers who drive dangerously and are careless about security but aside from the "bonus-malus" (no claims bonus) compensatory mechanism there is no way of knowing who these people are so it has to be presumed that everyone is equal until accident or theft proves otherwise. There is room for improvement, notably by increasing insurance premiums for each traffic offence as is the case in Canada.

Carried over to the health insurance arena,  while many of us would be happy to see the bad driver car insurance principle applied to smokers, drinkers and the obese who abuse their health, we would be less inclined to think it should be applied to people who are merely unlucky in life's birth lottery.

8/
MikeP makes an irrelevant point. when he says "I can choose the level of insurance I want for my car and my house, over the legal minima, so why not my health? "  That is exactly what the French system does.

If you don't want the "extras" then you don't pay for a "mutuelle". The minimum care (albeit of a high level) is all you get for the obligatory basic payment.

But the important point is this and was mentioned above. A system like car or house insurance which offers many varying levels of cover according to what one wants to pay would not be able to finance the necessary hospitals, emergency services, IRM (MRI) machines, medical laboratories, research, operating theatres, doctors and nurses training, the way the obligatory minimal public system does. So where would this individualised pay-as-you-wish care be exercised? Nowhere, that's where. Because nobody would be paying to build the facilities.

Does your car insurance company pay for the garage that services and repairs your car? Does it pay for the policemen that patrol the roads for your safety? Does it even subsidise the amulance that comes if you have an accident that your insurer will eventually pay the mechanical (but often not medical) damages of? Does your car insurer build and maintain the roads you drive on, in the way the Sécu pays for the medical facilities you're treated in?

The Sécu does all that and more, so to compare car insurance with public funded medical insurance is disingenuous to say the least.

9/
The hypochondriac problem is real and has been partially addressed by the "medecin traitant" amendment. No longer can they easily flit from doctor to doctor at the public expense. And the newly proposed prescription charge should significantly reduce the number of people who abuse the system by claiming for aspirin for a mere headache. There are issues with the French Sécu, that is certain.

To conclude:

There will always be needless bureaucracy and abuse in any system anywhere but it's not as nearly as rampant in French health care as many suggest. Benefit fraud in the UK is endemic to a point that makes France look severely restrictive by comparison. In spite of the flaws, we get better care for less money per patient than anywhere else I've seen.

On a per capita basis America spends 30% more than France does on health care and still manages to have almost 50 million of its citizens medically uninsured. A bout of pneumonia or a serious accident and these people's lives are effectively finished. They can never pay off the debt brought on by their illness or accident and some of them don't even try. They just let themselves die.

If that's what Americans want (and the health care plank in Obama's election platform suggests they no longer do) then that's just fine and it's their own business, but the majority of the French (and me) don't want a system where health care is dispensed based upon one's ability to pay rather than the reality of one's medical condition. That's democratic freedom of choice for you -- each country gets to pick the system prefered by the majority of its citizens.

No system is perfect but the French system is closer to it than most. There are some countries that are every bit as good but at a much greater cost to the taxpayer -- Denmark and Switzerland for example.

To really conclude:

A final note on the various organisations with comically acronymic names.

Historically this is an interesting story.

When universal health care was introduced in France just after WWII everyone paid a central Sécu the same amount in percentage of earnings and got the same coverage. But many industries -- and particularly the self-employed -- were very unhappy with this.

The argument at the time was that the self-employed would self-medicate (cognac?) and go to work through a bout of the flu or a headache while the salaried had time to go to the doctor and would take paid time off. People in professions that comprised a real health risk (like miners) would come down ill or injured much more often than accountants or bank clerks. So the system was divided up into professional segments at the insistance of the insured themselves who quite rightly didn't trust government to handle matters in a fair and equitable manner. Corresponding organisations were formed privately, each fixing their subscription amount and conditions based upon the general risk in their particular sector of activity.

To this day it is not the state that fixes the level of payment in each sector. It is the sector itself that self-governs its incomings and outgoings as part of the overall public system to which everyone contributes. The officers of these profession-based private "caisses" (with absurd acronymic names) are elected by the businesses that pay in, not appointed by government. In fact, the two are in constant battle.

The URSSAF is not a government controlled organisation at all. It is private but regulated. Its employees are not civil servants, but workers in the private sector. Any business person who doubts this should ask the URSSAF inspector next time he comes to call. I did.

This multi-segmented system of "caisses" is  something that has degenerated into somewhat of a shambles over the years and it needs another look. Sarko says he'll get around to reforming it when he can. There'll be much moaning when he does.