French-Style Healthcare Reform: A Moderate Proposal

Just after becoming the presumptive Democratic nominee earlier this month, Joe Biden publicly endorsed lowering Medicare’s eligibility age from 65 to 60. Despite the extraordinary health crisis that has coincided with the 2020 presidential race, this is hardly an ambitious proposal: even alongside his plan for a public health insurance option, it is far less sweeping than Bernie Sanders’s call to extend Medicare to all Americans as well as non-citizens. It is also less generous than his predecessor Hillary Clinton’s plan in 2016, which would have allowed Americans to opt into Medicare starting at age 55. Many have interpreted Biden’s Medicare plan as an attempt at a concession to the Sanders left, which has made the demand for universal healthcare its central issue. But Biden was also constrained (or at least believed himself to be constrained) by the need to keep his distance from anything that would come close to a full nationalization of the healthcare system. After winning a primary framed as a battle between socialists and moderates, Biden was not about to suggest that he was anything other than a moderate. It is not surprising that the resulting healthcare plan is underwhelming.


What is surprising is the lack of imagination—both throughout the primary and in response to the Covid-19 pandemic—as to what a “moderate” alternative to Sanders’s Medicare for All plan might look like. Asserting that Sanders’s plans are too radical, Biden and his fellow centrist contenders have proposed little that was not already envisioned by the Affordable Care Act a decade ago (Biden’s most ambitious proposal, the public option, was famously abandoned in the push to pass the ACA through Congress). Even before the current crisis had pushed tens of millions off of their employer-based health insurance plans, Biden’s proposal was on track to leave 10 to 15 million without coverage. While preserving the status quo would have been bad policy under ordinary circumstances, we are now more than ever living in times that call for comprehensive changes to the US healthcare system.


Biden’s hesitancy to think deeply about the fundamental flaws of this system is all the more unfortunate, because there are healthcare models that could be seen as “moderate” alternatives to Medicare for All—in the sense that they would do more to avoid disrupting existing providers and insurers—that could be far more effective in guaranteeing all Americans the care they need as the employer-based system crumbles all around us. If Biden and those around him are serious about reaching out to Sanders’s supporters, they ought to take a page out of the Vermont Senator’s book and look abroad for examples of what this might look like. While Sanders often speaks favorably of the healthcare systems in Canada or the United Kingdom (despite the fact that Medicare for All is not a fully nationalized NHS-style plan), Biden might find a model that is more compatible with with American institutions as they exist today in the French healthcare system.


The French model is effectively a hybrid between the sort of universal single-payer system Sanders has demanded, and the existing American system of employer-provided private insurance. Everyone in France is entitled to universal healthcare through a “Social Security” system that covers the vast majority of essential medical procedures and treatments. The basic care provided by Social Security is in fact quite generous, covering not only primary care, prescriptions, and emergency procedures, but also in-home nursing care as well as pre- and post-natal care for all mothers.


However, Social Security does not cover everything; the remaining costs of healthcare are covered either by supplemental private insurance, provided by employers, or means-tested state programs for the most vulnerable populations. More than 90 percent of the French population has this supplemental private insurance, which covers roughly 13 percent of total health expenditures. French patients pay only about 7 percent of pocket payments (co-payments exist for certain services, but are quite low, including €2 for an ambulance ride, or €18 for inpatient hospital care). As a result, hardly anyone in France is denied needed care because they can’t afford it, and no one is forced into medical bankruptcy.


Despite common criticisms from American opponents of universal healthcare, individual freedom is one of the cardinal principals of the French healthcare system and health law. Since Social Security and all private insurance plans are accepted everywhere, patients can choose their doctor and hospital. Knowing they will be reimbursed for their services no matter what, physicians can choose the treatment their patients need, not what insurers will pay for.


To be sure, a French-style healthcare plan would satisfy neither the moderate wing nor the democratic socialist wing of the Democratic Party. Moderates will likely worry that the French system is too expensive (as they have claimed of Medicare for All); the Covid-19 pandemic, however, is a perfect opportunity to revise some of the prevailing dogma among conservative Democrats about how much debt the state can take on to address urgent health needs. Meanwhile, socialists would prefer to eliminate the private insurance industry entirely, transforming healthcare along with other essential goods into fully public goods. But as with any compromise, this plan would leave both sides with priorities for future reforms. A French-style system would satisfy the moderate wish to preserve the private insurance industry, but would shrink its size and its importance—allowing socialists to dream of how they might one day drown it in a bathtub. At the same time, it would satisfy the socialist aim of offering benefits universally—though fiscal moderates and conservatives might later seek to restrict what services are covered (as has been in fact been the case in France).


For better or worse, Biden has won the Democratic primary, and neither the Covid-19 pandemic nor the spirit of compromise have led him to reconsider his opposition to Medicare for All. But he has also said, as he did in a statement soon after Sanders left the race, that “while Bernie and I may not agree on how we might get there, we agree on the ultimate goal.” Embracing a French-style plan—a universal system to cover everyone’s basic needs while letting private insurance and means-tested programs do the rest—would enable Biden to prove that he and Sanders in fact do agree on the necessity of providing healthcare to everyone, without requiring that he concede fully to the democratic socialist approach.


Americans do not always like to look abroad for answers in a political crisis, and perhaps least of all to the French. But if Biden’s “moderate” wing of the Democrats hopes to unify the party and create a more humane healthcare system out of these pandemic conditions, the French system is an attractive source of ideas for a potential reconciliation with the left.


Photo Credit: U.S. Department of State, via Flickr, Public Domain.


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  • Thomas Holzman says:

    I have heard some people describe the French system as equivalent to Medicare for everyone. This seems like a reasonable description. I hope, if Biden wins, he will embrace something like this.

  • Daniel says:

    Very interesting middle way.

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