Published May 16, 2019
National Review - June 3, 2019 issue
One of Charles de Gaulle’s most notorious moments of public wit came when he was asked at a press conference whether “Europe” wasn’t the solution to France’s problems. After a long defense of his policies, he exclaimed: “Of course, people can jump up and down on their chairs like mountain goats and shout ‘Europe! Europe! Europe!’ but it means nothing and leads nowhere.” It seems that when it comes to health-care reform in the U.S., progressives often think it’s enough to jump up and down like mountain goats and shout “France! France! France!” But it’s not. I am proudly French, and I have seen the problems of socialism in my nation firsthand.
Let’s get the obvious out of the way first: Yes, the French health-care system is, at the moment, almost as amazing as they say. Taking my frighteningly sick daughter to Necker, the main children’s hospital in Paris, made me proud to be a French taxpayer. Not only was the building gleaming and everything in it high-tech, but the staff was first-class, efficient, and, above all, kind, a world away from bureaucratic cliché. When, on my way out, after my daughter had recovered, I asked whether I had to pay for anything, the staff looked at me as if I’d just flown in from Mars.
Nonetheless, the French system offers virtually no lessons applicable to the United States.
Progressives either dislike private insurance or want to ban it outright; the French system relies on private insurance. Health-care wonks left and right agree that the biggest problem of the U.S. system is that it is employer-based. French health care? Also employer-based.
Since long-term and so-called lifestyle diseases such as obesity, diabetes, and heart diseases currently pose the biggest threats to public health, progressive health-care wonks are obsessed with preventive care. What’s one of the few areas where French health care lags behind the rest of the world? Preventive care.
Another progressive villain is prescription drugs, and France is a notorious over-consumer of them. While progressives are rightly enthralled with the idea of “evidence-based medicine” (while failing to realize that mandating it is sure to bring dysfunction), the French government has found a, let’s say, ingenious way to get French people to ingest fewer drugs: It promotes the notorious fraud of homeopathy and, in some cases, even pays for it. The French are also inexplicably obsessed with psychoanalysis, to the point that French mental-health care is essentially stuck in the 1930s. In the name of environmentalism France has long banned genetically modified organisms that science says are harmless for humans and good for the environment, and the government recently bowed to public pressure and passed a partial ban of glyphosate, a herbicide that activists say causes cancer even though scientific studies have found no such link. (Activists say these results are due to a conspiracy; 80 percent of French people support a ban.)
Progressives advocate information technology as a way to make the U.S. health-care system more efficient (again: excellent idea in the abstract, a disaster if you do it via central planning); France is a health-IT laggard.
Progressives routinely point to inequalities in life expectancy between the richest and poorest Americans, often implying that imitating policies such as France’s would reduce the difference. The Washington Post called the American life-expectancy gap “stunning,” and Vox blamed it on the Trump tax cuts — really. Such claims imply that America’s socioeconomic system is notably bad when it comes to health and death. They don’t say it outright, though, because, compared with other OECD countries, the United States is in the middle of the pack for health inequality — right where France is.
So if French health care is so similar to health care in the U.S., how does it manage to have such different outcomes? The answer is that France, with its tradition of state-directed authoritarianism, is able to achieve something that is politically radioactive in the U.S.: severe cost control. France has the lowest doctor pay, relative to average income, in the OECD. A young general practitioner in France made 69,900 euros on average in 2011 (roughly $97,200 at the time), according to the French National Statistics Office. Currently, nurses make 21,840 euros (around $24,300) on average. Despite having to hold the equivalent of a bachelor’s degree, French nurses make 5 percent less than the average income, according to OECD figures.
Which is a natural response to the financial stress on the system. While the French health-care system is presently good, it is also, well, dying. It has its own dedicated tax revenues and spending streams — every year, the French parliament votes on not one budget but two: one for general government and one for health care. The system has been running a deficit every year since 2002. France spends around 11 percent of its GDP on health care every year, which is certainly less than that crazy outlier America but still very high compared with the rest of the OECD. Government spending is already at around 56 percent of GDP, and given EU-imposed budget rules there is not much room to spend more — even as the wave of Baby Boomers is retiring.
Which doesn’t leave many options besides squeezing more hours out of already-underpaid workers and cutting benefits. While nurses’ salaries stagnate, their working hours keep increasing. According to a survey by the National Order of Nurses, 63 percent of nurses show at least one symptom associated with occupational burnout, and 25 percent have sought psychiatric help as a result of work-related stress. In the health-care utopia of France, 22 percent of nurses polled say they are seriously considering getting into a different line of work.
And there aren’t many ways left of decreasing costs. Rural hospitals have been merged, creating so-called medical deserts — large areas with no doctors. In 2017, three years’ worth of incident logs from the central teaching hospital in Toulouse, a trove of 26,000 documents, was leaked to the media. Toulouse is a large city known for its picturesque center, nearly year-round Mediterranean sunshine, good universities, a winning rugby team, and being one of the hubs of France’s vaunted aerospace industry — all Airbus jets go through final assembly in Toulouse. If you were looking for a place to represent the best of French health care, the teaching hospital in Toulouse would be a top candidate. And yet those incident logs tell a different story.
In a French hospital, each time something unexpected happens, an incident log is filled out. While most of the 26,000 log entries represent the normal imperfections that are found in any organization, “more than a thousand are a sign of poor . . . conditions . . . that can threaten patients’ lives,” said Sylvain Morvan, editor of the local news site Mediacités, which unearthed the documents. Requests to fill holes in the floor received no response for two years. Overweight handicapped patients were left to lie in bed indefinitely for lack of suitable equipment to help them up, leading to further health troubles and depression. In one log, a nurse wrote, “My team is exhausted, physically and psychologically. . . . We feel like we are not doing our jobs well and endangering patients’ lives.”
There’s another way in which the French health-care system stands out: It has the lowest share of out-of-pocket spending in the OECD. There’s hardly anyone who doesn’t think that has to change; in the immortal words of Barack Obama, “it’s arithmetic.” Perhaps, say hopeful center-left reformers, more cost-sharing will lead to more competition and innovation, which sounds awfully . . . conservative. The French health-care system has turned out to be a good illustration of Margaret Thatcher’s quip that the problem with socialist governments is that sooner or later, “they always run out of other people’s money.”
With demography putting re-lentless pressure on costs even as budget constraints mean spending must go down, I always hear the same story from nurses, doctors, and administrators I interview: Yes, right now we are doing okay, but the system will collapse sooner or later.
And that is a story you can tell about the French welfare state in general. As Democratic presidential candidates contemplate proposals such as universal day care and free college tuition, they would again do well to look at France — actual France, not the fantasy of progressive propaganda.
American writers often laud the supposedly wonderful French public day-care centers. In 2013, Pamela Druckerman, the author of Bringing Up Bébé, the book that identified a supposedly superior French style of parenting (remember that?), wrote a typical op-ed in the New York Times urging America to “catch up with France on day care.” As someone who lives in France, has a young child, and has many friends with children, I’ve certainly heard lots of very nice things about French day-care centers, known as “crèches.” But I’ve yet to meet anyone who has experienced them firsthand. As I wrote back in 2013: “When my wife got pregnant, we duly went to the local crèche office to apply for a spot (well over a year in advance!). When we asked how likely we were to get one, the nice lady simply laughed. She could put us on the waitlist, she said, but that almost certainly wouldn’t make a difference.”
The French government seems to have given up on trying to make up for the shortfall. Back in 2012, François Hollande was elected president partly on a promise to create tens of thousands of new spots in crèches, but he essentially abandoned that promise on Day One. There are now regular news stories about corruption in the awarding of crèche spots. All of this was predictable: Public provision of important goods leads to rationing and thence corruption.
Pro-family policy has been one of the most ancient and cross-ideological commitments in French politics. France’s war defeat by Germany in 1870 was seen as the result of Germany’s higher fertility rate, and raising fertility was thereafter considered necessary to win the eventual rematch. Pro-family policy was embraced by the left-wing Popular Front in the 1930s and the Vichy regime in the 1940s, and in the post-war cross-party settlement it was embraced as one of the three “pillars” of France’s new welfare state, alongside socialized health-care coverage and redistribution.
This commitment has changed only recently. Obediently following German instructions to reduce the deficit, François Hollande passed unprecedented cuts in family benefits, which now nobody talks about reversing, and the Macron administration occasionally floats proposals for further cuts as a way to balance the budget — to a silence that is striking, given French tradition. Everyone knows why: There’s no money anymore.
As for college, far be it from me even to indirectly endorse the insane American higher-education bubble, but every time I cross an American college campus I feel a pang of envy. France does have “free college,” of a sort. Its higher-education system is a massively complex tangle of various types of institutions awarding various types of credentials to various types of students. Any high-school graduate (which means, in practice, almost every 18-year-old) is entitled to a spot at a free public university — which makes it odd that private higher education in France is thriving, with close to 20 percent of students going that route. Between 1998 and 2016, private higher-education enrollment grew by 88 percent, as opposed to 14 percent for public higher education.
The explanation cannot be prestige, as might be the case among America’s elite universities, since France’s most prestigious schools are all public. Nor are private institutions massively subsidized — government funding represents a modest 7 percent of private higher-education institutions’ budgets on average.
The answer becomes obvious when you actually set foot in one of those public universities. My top-ranked law school’s library, for instance, on top of being crumbling and having Wi-Fi that didn’t work most days and only a handful of computer terminals, had a glass wall oriented so that sunlight hit it directly. That wall, combined with a lack of air conditioning and ventilation, turned the library into a locker-room-scented sauna — especially in the spring, which is exam season — with predictable consequences for library attendance.
Then there’s the matter of elitism. The world of public universities and professional schools exists apart from the schools that give you a ticket to the French elite. These, the grandes écoles (literally, great schools), are where upper-crust parents want to send their children. Unlike public universities, which are open to all high-school graduates, these tiny schools can be entered only via brutal competitive examinations that require two to three years of post-secondary studies. Students who want a shot at the top universities must typically spend 70 to 80 hours a week cramming in an intensely competitive atmosphere, with predictable effects; suicides at the top prep schools are a fact of life, accepted by all.
So it’s no wonder that even though there are free public prep schools, students from unprivileged backgrounds cannot compete in them. It’s impossible to study 70 hours a week if you also have a long commute, which would be the case for anyone who lives outside the expensive city centers where the best prep schools are. Free universities turn out to be not so much a commitment to social equality as a handout to the plebs so that they don’t demand access to the actual paths to elite status.
There is a recurring theme. Somehow, every supposedly progressive French policy turns out to have the same effect: to cement the power of the upper middle class and sap upward mobility. Labor-market regulation is great for grande école graduates; it’s not so great for the lower-skilled, who must make do with temporary jobs since employers are reluctant to be locked into expensive labor contracts. Housing-market regulations, supposed to protect tenants from abusive landlords, artificially prop up housing prices and subsidize elderly rentiers even as they make it hard for the underprivileged to find housing. And so on down a very long list.
It is difficult to see all this as a coincidence, given that the people who make the rules are those who benefit. Since the election of Emmanuel Macron, more and more observers have become aware that virtually all of France’s leadership roles are held by people who went to the same schools and share the same background. Macron describes himself as a progressive, and people like him believe that, owing to their superior education, they have the right to order society for the benefit of everyone. Given the results — low growth, mass unemployment, social strife, and a general mood of pessimism (80 percent of French people believe their children will be worse off than they, the highest rate in Europe) — they might want to rethink their idea of progress.
This article appears as “All the Benefits You’ll Never See” in the June 3, 2019, print edition of National Review.
— Mr. Gobry is a fellow at the Ethics and Public Policy Center.
