Sunday Forum: The French and Dutch do health care right

And their approach is more replicable here than the more often cited systems of Britain and Canada, says JONATHAN COHN

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I don't want America to begin rationing care to their citizens in the way these other countries do.

That was Arizona Senator Jon Kyl, speaking last month about health-care reform. But it could have been virtually any other Republican, not to mention any number of sympathetic interest groups, because that's the party line for many who oppose health-care reform. If President Barack Obama gets his way, this argument goes, health care in America will start to look like health care overseas. Yes, maybe everybody will have insurance. But people will have to wait in long lines and the care won't be very good.

Typically the people making these arguments base their analyzes on one of two countries, Canada or England, where such descriptions hold at least some truth. Although the people in both countries receive good health care -- their citizens do better than Americans in many important respects -- they are also subjected to longer waits for specialty care and tighter limits on some advanced treatments.

But no serious politician is talking about recreating either the British or the Canadian system here. The British have truly "socialized medicine," in which the government directly employs most doctors. The Canadians have one of the world's most centralized "single-payer" systems, in which the government insures everybody directly and private insurance has virtually no role.

A better understanding of how universal health care might work in America comes from other countries -- countries whose insurance architecture and medical cultures more closely resemble the framework we might create here.

Last year, I researched two of these countries: France and the Netherlands. Neither country gets the attention that Canada and England do.

Over the course of a month, I spoke to just about everybody I could find who might know something about these health-care systems: Elected officials, industry leaders, scholars -- plus, of course, doctors and patients. And sure enough, I heard some complaints. Dutch doctors, for example, grumbled about paperwork. French experts thought patients with chronic disease weren't getting the kind of sustained, coordinated medical care they needed.

But not once did I encounter someone who wanted to trade places with an American. And it was easy to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care.

Physicians felt free to practice medicine the way they wanted, companies could concentrate on their businesses instead of managing health benefits and everybody had insurance. The papers weren't filled with stories of people going bankrupt or skipping medical care because they couldn't afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

The Dutch and the French organize their health care differently. In the Netherlands, people buy health insurance from competing private carriers; in France, people get basic insurance from nonprofit sickness funds that effectively operate as extensions of the state, then have the option to purchase supplemental insurance on their own. (It's as if everybody is enrolled in Medicare.)

But in both countries virtually all people have insurance that covers virtually all legitimate medical services. In both countries, the government is heavily involved in regulating prices and setting national budgets. And in both countries, people pay for health insurance through a combination of private payments and what are, by American standards, substantial taxes.

You could be forgiven for assuming, as Sen. Kyl and his allies suggest, that so much government control leads to Soviet-style rationing, with people waiting in long lines and clawing their way through mind-numbing bureaucracies every time they have a sore throat. But both the Dutch and French appear to have easy access to basic medical care -- easier access, in fact, than is the American norm.

In both the Netherlands and France, most people have long-standing relationships with their primary-care doctors. And when they need to see these doctors, they do so without delay or hassle. In a 2008 survey of adults with chronic disease conducted by the Commonwealth Fund, 60 percent of Dutch patients and 42 percent of French patients could get same-day appointments. The U.S. figure was just 26 percent.

The contrast in after-hours care is even more striking. If you live in either Amsterdam or Paris and get sick after your family physician has gone home, a phone call typically will get you an immediate medical consultation or, if necessary, a house call. And if you need the sort of attention available only at a formal medical facility, you can get that, too -- without the long waits typical in U.S. emergency rooms.

This is particularly true in the Netherlands, thanks to a nationwide network of urgent-care centers the government and medical societies have put in place. Not only do these centers provide easily accessible care for people who use them; they leave hospital emergency rooms free to concentrate on truly serious cases.

Dutch and French patients do wait longer than Americans for specialty care; around a quarter of respondents to the Commonwealth Fund survey reported waiting more than two months to see a specialist, compared to virtually no wait for Americans. But Dutch and French patients were far less likely to avoid seeing a specialist altogether -- or forgoing other sorts of medical care -- because they couldn't afford it. And there's precious little evidence that the waits for specialty care led to less effective care.

On the contrary, the data suggest that while American health care is particularly good at treating some diseases, it's not as good at treating others. (In some studies, the United States did well on cardiovascular care, not so well on diabetes, for example.) And overall, the United States fares poorly on measures like "potential years of lives lost" -- statistics compiled to measure how well national health-care systems perform. In a 2003 ranking of 20 advanced countries, the United States finished 16th when it came to "mortality amenable to health care." The Dutch were 11th and the French were fifth.

These statistics are necessarily crude; diet, culture and many other factors affect the results. But, taken together, they make it awfully hard to argue that medical care in these countries is somehow inferior. If anything, the opposite would seem to be true.

None of this is to say that either the Dutch or French systems are perfect. Far from it. In both countries, health-care costs are rising faster than anyone would like. And each country has undertaken reforms.

The French have started to introduce some of the managed-care techniques familiar to Americans, like charging patients extra if they see specialists without a referral, while developing more evidence-based treatment guidelines in the hope of reducing the use of unnecessary but expensive treatments. The Dutch overhauled health insurance a few years ago to introduce more market competition and reward doctors and hospitals that get good results.

But cost is the one area in which France and the Netherlands are a lot like Canada and England: They all devote significantly less of their economy to health care than we do. The French spend around 11 percent of their gross domestic product on health care, the Dutch around 10 percent. We spend around 16 percent. And, unlike in the United States, the burden of paying for health care in France and the Netherlands is distributed across society -- to both individuals and businesses -- in an even, predictable way.

The changes now under consideration in Washington are relatively modest by international standards. But insofar as countries abroad give us an idea of what could happen if we change our health-insurance arrangements, the experience of people in Amsterdam and Paris surely matters at least as much as those in Montreal and London.

In France and the Netherlands, government intervention has created a health-care system in which people seem to have the best of all worlds: convenience, quality and affordability. There's no reason to think the same thing couldn't happen here.


Jonathan Cohn , the author of "Sick: The Untold Story of America's Health Care Crisis -- and the People Who Pay the Price," is a senior editor for The New Republic.


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