How Socialized Medicine Works in France

Socialized Medicine in FranceIhave reached a hoary age where more and more of my comrades and contemporaries are having more and more medical problems and more an more operations. Worse still, they want you to listen while they talk about them, often in gory detail, after you have spent the better part of the morning cheerfully trying not think about your own medical problems by concentrating on the civil war in Syria or capitalism’s structural inability to stop causing catastrophic climate change. Accordingly, my screed today (although it does contain the words ‘my operation’) concerns health solutions (not ‘problems’) here in Montpellier, France.

I am once again amazed by how well run is France’s free health system (known as ‘Social Security’ or La Sécu), and I am eager to share my personal experience of the possible with my friends in the U.S. for whom accessible healthcare remains a constantly receeding mirage. (I read that Obama’s IRS is now stripping family coverage from millions of working poor based on a loop-hole in the bill passed by Congress.) Within a few weeks of returning here from New YOrk, I have seen seven doctors and been schedualed for three (count ‘em 3) separate operations: transplants of lense for both eyes plus carpal tunnel. All of these services will cost me next to nothing. The personnel and record-keeping system are highly professional, efficient, and, except for a few sourpuses, cheerful and fun.

The original elements of French Social Security (including protections for unemployment, retirement, work accidents, illnesses and such), go back to the dictatorship of Napoléon III who recognised and encouraged mutual aid societies among workers and tradespeople and wished to imitate his Prussian rival Bismark’s bureaucratic plan to domesticate the unruly German working classes through state-run welfare. From the 1890s on, the Third French Republic incorporated and funded more and more mutuels, including among the peasantry. After WWII, the right to health and welfare coverage for every citizen was incorporated by the Resistance into the 1945 Constitution. Over the years, the coverage of the Sécu, incorporating various mutuels and employee-employer funded schemes, has become more and more universal, culminating in 1999 with the extention of full medical coverage to everyone living in France, including me.

Here’s how the system works today. As a foreigner, I pay an annual premium based on my income level (based on my US tax return). I then pay cash for office visits and prescriptions (not always easy for poor folks) and get reimbursed 60% to 80%. In addition, I subscribe to a mutuel that makes up most the difference.

First I go to Dr. Foissac, my family physician here since 1985, who lives and works a block and a half away. No appointment. He also makes house calls, but bawls you out if he thinks you’re not really sick enough. As usual, there are a few people standing in front of the building at 14h15 and so I am fourth on line when Robert walks up, shakes everybody’s hand, and opens the door not very promptly at fourteen thirty-something. This is the infamous bureaucratic ‘depersonalization of medicine’ that according to the AMA would be the inevitable result of ‘state-run, socialised medicine.’ However, it was in Hartford, Connecticutt, the insurance capital of the US, not France, that I was no longer able to see my family physican because was in a different network than the one my employer’s insurance company worked with. And I had to wait months to get to see a primary care physician for an initial examination.

A short wait and then Robert examines me, writes about six prescriptions in record time: blood tests, nerve tests, MRI, etc. and referral permissions to consult the necessary specialists, for my hand and eyes, plus the sports med doc for my trick knee. Since he knows I am in a hurry, he personally calls one specialist’s office and asks them to squeeze me in the next day. I pay him 23€ in cash, which will be reimbursed by the Sécu plus Mutuel that takes up the slack. At one point we arm-wrestle across his desk to settle a disputed point (after he calls me a ‘drug addict’!) and he is surprised when I beat him, considering he’s a sportif and I a bookish slug.

Next come various visits for pre-admission to hospitals (all walking distance) including pre-op visits to the two different anesthetists. All kinds of instructions to patient. I must take showers with red anti-septic scrub night before AND morning of operation, etc. Various permissions. Drops to take an hour before the eye operation. Lots of precautions. Everything goes on my green Carte Vitale, hooked up to the Sécu. The French also are apparently installing a central Internet medical file so that if I have a health emergency in Paris, they can see my records here.

Not much waiting except in one office, two hours to see the anesthetist for five minute. Lots of maternity happening in this waiting room. The tall, slim Fnechwoman opposite me is carassing a belly as big as a basketball, and occasionally breaths as if in labor. She is replaced by another slim, pregnant Frenchwoman and her husband, a 6’3″ black African so handsome I had to hide my eyes behind the New York Review of Books so as not to be seen staring with admiration.

I am seated next to a mod-chic Arab couple and their little boy, who has sharp jelled hair, like his Dad. She’s pregnant. The Dad and boy go get a coke. An hour later, I get thirsty too and ask the man where is the machine. He says it’s complicated and offers to guide me. Embarrassed, I accept and we go out into the heat and across the campus and in a little door. It was indeed too complicated to explain in words. Next, to my embarassment, I don’t have the right change. My guide insists on paying for my drink and solomnly refuse the change I have as part payment. It is his pleasure, and he sketches a gesture of hand toward heart. I thank him and remember it is Ramadan, a time for generosity.

I had been afraid I would once again need spinal surgury for the fourth time to get rid of the permanent pins and needles in my left arm and the increasing loss of sensation in fingers making it impossible to button shirt sleeves and unpleasant to play piano or type. This tingling also happens in bed — not good for falling back to sleep after being awakened by sleep apne several times a night.

Mais, non! The nerve doctor sticks needles in my arm, sends electric shocks from one place to another and records the times. Very slow in left arm. Et voilà; Blockage in carpal tunnel. If I wait much longer, I lose nerve and end up with gnarled hands like old peasants you see in villages.

Dr. Amara, the Lebanese hand surgeon at the Hand Center a short bike ride away remembers me from 10 years ago and again recounts tales of his apprenticeship at the world-class hand center in Indianapolis. He says US high end medicine is in a class by itself, but the spectrum is unbalanced at the other end. We joke. He’s happy to pencil me in for the next Tuesday, and I’m off on another round of pre-op visits, this time with a signed statement by my family doctor (Robert) listing all the treatments I take to be submitted to the anesthetist. More precautions.

First operation. In hospital 7:30 am. Holiday atmosphere, everybody tanned and fit, lots of banter and people in medical disguise rushing purposefully about. Meanwhile I’m strapped on a table with lots of hookeedoes attached. The female personnel are all friendly and attractive, and reciprocate when I flirt with them, the more outrageously the better. Good for everybody’s morale. Once they reassure me that they are not going to operate out here in this busy corridor, but in the OR next door, I slide into euphoria. The surgeon, my eye doctor Mr. Millet, arrives. Greetings all around. Banter as he scrubs up. Then I don’t remember what happened in the OR, although all they gave me was eyedrops for local anesthesia. Maybe they dropped some opium in there too? I remember walking back to my room on the chubby arm of a short nurse, and later walking home on Elyane’s.

I am out of pocket about 600€ of extra fees (some of which may be reimbursed by my Mutuel, we’ll see) which the two surgeons now have the special right to add to their regular tarrif of fees, which are quite modest and fixed by the Sécu at a standard fee for each type of operation. One of a number of recent inroads of privatisation. On the other hand, I can’t blame them! They work hard, are highly professional (and closely monitored) and even the specialists are hardly rich by US doctors’ standards!

Of course, this is an idealised picture. Montpellier has been a major medical and pharmaceutical center since the 12th Century. (Rabelais got his doctorate here in the 16th). I wouldn’t care to be operated in Nîmes, up the road.

There’s also the other, darker side of the French coin of a welfare state built on a colonial empire. A massive crackdown on immigrants whose papers are not in order — including Yours Truly who stupidly neglected to renew his Carte de Séjour and is now ‘in an irregular situation.’ Moreover, as a non-European, I fall into the same category as immigrants from North Africa, West Africa, and East Europe, many of them desperate and poor. Every year we non-Europeans line up early in the morning all around the block in front of the Préfecture in order to get a ticket and wait to present our applications. The tickets run out early. Last year I had 169, and was one of the last. This year it’s different. Routine renewal is by appointment via Internet, but people ‘en situation irrégulière’ have to line up on Thursday or Friday mornings to be processed.

When I get there, I notice a small crowd of Moslem women waiting in the square. The Prefecture itself was closed to anyone without proper papers. From now on the tickets are given out by the policeman guarding the outer entrance gates. I asked him how early I needed to be there in order to have a good chance of getting a ticket: 5 am? 6 am? He pointed to the little crowd of older women wearing headscarves in the square: they’re already on line for tomorrow! ‘How many tickets to you get to give out?’ I asked. ‘Thirteen,’ came the reply. It’s as if suddenly the whole Prefecture had only enough personnel to handle 26 files a week (instead of 800 or more)! An impatient official behind a desk gave the real explanation unblushingly: “There are too many foreigners in France.”

I wanted to tell her that there weren’t ‘too many foreigners in France’ in 1917-18, when my Dad came over as an ambulance driver in a French regiment, won the Croix de Guerre and ended in a military hospital for foreign troops along with tall Black Senegalese lancers and diminutive Vietnamese ditch diggers. Or again in 1940, when French officials like her were collaborating with the Nazis and Dad and his buddies again drove ambulances (on the home front) while Algerians and Spanish Republicans, equally undesirable, helped liberate Paris. But of course I didn’t think of it until I was half-way out. The French call this ‘l’esprit de l’escalier’ – the brilliant retort you think of as you’re on the way downstairs from the salon where you’ve been humiliated.

Richard Greeman

Posted: Tuesday, 21 August 2012

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