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We've covered the United States and Canada. today, we cross the Atlantic to discuss the healthcare System in France. Their system is a combination of universal social insurance with some optional private overlays. It's expensive (relative to most), but it's arguably the best in the world. Watch and learn why.

Those of you who want to read more and see references can go here:

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
There's a saying I'm quite fond of, although I'm not sure who first penned it: "The French love their healthcare system, and change it all the time. Here in America, we hate ours, but refuse to touch it." There's some truth to that, there's also a lot that much of the world could learn from France. Their healthcare system is the topic of this week's Healthcare Triage.

Toward the end of World War II, the French realized their country was in pretty bad shape. There was little chance that the shattered private sector was gonna be able to take care of all the people who might need healthcare in the next few years. So France established a system of national health insurance in 1945.

The system is, ironically for those of us in the United States, known as Social Security. Everyone in France must pay for mandatory health insurance. Insurance is obtained from non-profit funds. There really isn't any competition and there really aren't many choices.

There are 5, known as General, Independent, Agricultural, Student, and Public Service. One fund alone covers almost 85% of all people in France. I'll give you 3 guesses which one it is...

They all have pretty much the same benefits and the same reimbursement. The only people who don't fall into one of these 5 funds are people who have never worked or aren't covered by other sources. For those people, the government has its own plan, financed by taxes, that reimburses better than the other funds for people like the very poor who can't make out of pocket payments.

These funds funds are financed largely by the public. More than 40% of healthcare spending is financed by payroll taxes and about a third from income taxes. The rest comes from tobacco and alcohol taxes, some transfers from other branches of Social Security, and a small amount from state subsidies. All together, this covers more then three quarters of all healthcare spending.

This insurance covers a lot: inpatient and outpatient care, specialists, dentists, midwives, diagnostic tests and services, prescription drugs, medical devices, mental health, even health related transportation. Stuff we'd never consider covering in the United States is included. Things like homeopathy, house calls, amazing maternity benefits, and even child care. Social Security covers somewhere between 70 and 80 percent of costs, leaving the remaining amount in individual's hands. But there's also voluntary health insurance, provided by private insurance companies or by the government for those who are poor. This insurance covers many of the costs that Social Security doesn't. More than 90% of the French have voluntary health insurance plans, mostly through their jobs.

Almost 70% of primary care physicians, and more than half of specialists are self-employed. Again, France is not socialized medicine. About two thirds of hospital beds are owned by public or non-profit groups. The other third are owned by individuals or corporations, and are totally for profit businesses. Doctors make much less than those in some countries, maybe a third of what doctors do in the United States. But they get medical school for free, and they pay nothing for malpractice insurance. And if they agree to charge government approved rates, they get some of their Social Security taxes waived too. So it's not as much of a difference as it first appears.

Funds and budgets are set by the Ministry of Health, which also regulates the number of hospital bed, what equipment is purchased, and how many medical students are trained. The ministry also sets the prices for procedures and drugs, and defines priority areas for future focus and spending. It oversees agreements between Social Security and unions, which represent physicians. Doctors can choose to work outside of these agreements though, and charge more.

Patients have total choice of where they go for care and who they see. Because prices and reimbursement are set at a high level, they can go pretty much anywhere. There is some level of gate-keeping, where patients pay less if they get referrals to specialists before they go there. But those referrals aren't to specific facilities or physicians, they're just permission to choose what they want.

Most people in France pay very little themselves for their healthcare. After insurance kicks in, doctor visits cost one euro or less. A hospital stay can run as little as 18 euros a day, mostly for the room and board. Prescription drugs are like half a euro. All of these together are capped at 50 euros a year. An interesting of the system is that co-pays are regulated by sickness. People who have chronic conditions have all their co-pays waived. In other words, people who use the most care, in general, pay the least.

France also allows pretty impressive access. For instance, it guarantees that cancer patients can get any drug they want, even expensive or experimental ones. As I said in the beginning of this episode, the French love their system. In international surveys, it always kicks butt in terms of satisfaction. It also crushes the competition in terms of quality. In almost every international comparison, not matter what methodology you use, France comes out near the top, if not in first place. I've never met, and rarely read anyone who has a bad story to tell about their care there.

The knock against the French system is that it's expensive. And it is, compared to lots of other countries. Its four thousand one hundred and eighteen dollars per person is well above the OECD average of three thousand three hundred and twenty two dollars in 2011. But it's nothing compared to the eight thousand five hundred and eight dollars we spend in the United States. With respect to spending as a percentage of GDP, France is near the highest in the world at 11.6%. That's beaten only by the Netherlands at 11.9%, and of course the United States at 17.7%.
So everyone else in the world may have a genuine case when they claim that France is too expensive, but I laugh at anyone in the United States who says so.

Genuinely universal coverage, comprehensive benefits, complete freedom of choice of providers, top in the world outcomes. There's a good case to by made that the French have the best healthcare system in the world.