June 2, 2023

Dear Interested Readers,

 

Liberté, Egalité, Fraternité

 

“Liberté, Egalité, Fraternité” is the motto of France. It speaks to the high ideals of a country that is trying to improve the social determinants of health for everyone. The motto was first used during the French Revolution in 1789, and like the French Revolution itself is an outgrowth of the Age of Enlightenment. Liberty, equality, and fraternity may seem like obviously positive ideas but the slogan fell in and out of favor until it became part of the 1958 rewriting of the French Constitution. I have been thinking about what it means that while France was writing its new constitution which strictly separated church and state, we made “In God We Trust” America’s motto in 1956. 

 

It is my personal opinion that history suggests that liberty, equality, and respect for one’s neighbors have a better chance of thriving as concepts when there is clarity about the separation of church and state. It is ironic for me to consider that during my childhood in the fifties many Protestant ministers, my father included, were strong advocates for a strict separation of all things related to civic life and the church, and now the reverse is often true as we encounter “Christain Nationalism.” It seems that liberty, equality, and fraternity are at risk when the church and the state get together to decide who is in and who is out, and who is welcome as well as whether a woman can control her own reproductive choices or any individual can determine who they love and how they want to live. 

 

I am in the midst of my fifth trip to France and fourth trip to Paris. I first came in the summer of 1969 after spending most of the summer in a surgical research lab at the University College Hospital in London. I came back for several days in 1974 after driving in from Germany and Switzerland and returned once again in 1995 after crossing from England through the recently completed “Chunnel.” In 2013, we visited the part of France along the Rhine including Strasbourg. On this trip, we have been to Normandy to see the D-Day battle sights, spent a few days in Paris, and are now cruising down the Saône to Lyon and then down the Rhône River to Arles near the Mediterranean. So far the river trip has been a delightful journey through vineyards, gorgeous countryside, and interesting villages, towns, and cities. 

 

In all of my previous trips to France, I have paid more attention to the sites than to the people and French society. In the past, you were in for disdain if you could not speak French. This time there has been a noticeable change in attitude, and I have had more conversations. I have also made a little effort to learn some French thanks to “Duolingo.” During this trip, I have been curious enough about the French healthcare system to ask a few people about their healthcare experiences. What I have discovered is that people like it and trust it. Our guide in Normandy, a woman in her sixties, was enthusiastic about her care. She has had knee surgery and implied that she has had a chronic medical problem. She told me that she has zero out-of-pocket expenses. She gets all of her meds for free. She has not had delays in care and is very happy with the care that her ninety-year-old father gets. One of our drivers, a young man in his mid-twenties could not imagine what it would be like to get care in any other way. He proudly pointed out the large very modern hospital in his hometown of Caen as we drove by on the expressway.

 

The medical experience that I most enjoyed was a visit to the Hôtel Dieu (House of God) in Beaune. It was a free hospital built for the poor in the fourteenth century and operated as such until the 1970s when it was replaced by a new hospital. The “House of God” was not built by the church. It was built by a rich man and his wife with the hope that their kindness might be given some credit on Judgement Day.

 

 

We don’t usually think about the fact that before the late 1800’s most people of means preferred to stay at home when they were ill and not risk exposure or endure the inconvenience of hospitalization. The doctor and nurses would come to them. It was not until there were surgeries with anesthesia and diagnostic procedures like xrays that the hospital services migrated toward those who could pay.  

 

Over the last fifty-five years, both France and I have changed a lot. I have particularly enjoyed the French countryside with its small villages and towns that often still retain parts of their medieval walls or Roman influences, but I have also been fascinated with how the French seem to be on a totally different journey toward ensuring equity in healthcare. Even a very casual review of the objective data demonstrates that the French get much better care for about half of what we pay. I fear that I have been overusing ChatGPT, but it seemed appropriate to once again go to my new resource with some good questions. I decided to begin with a very general question so I asked:

 

How does the French Healthcare System differ from the American system of care?

[I have bolded important points.]

 

ChaGPT:

 

The French healthcare system and the American system of care differ in several key aspects. Here are some of the main differences:

• Universal Coverage: The French healthcare system provides universal coverage to all residents of France, regardless of their employment or financial status. It is based on the principle of solidarity, where everyone contributes to the system through mandatory health insurance contributions. In contrast, the American system does not guarantee universal coverage, and access to healthcare is often tied to employment or private insurance coverage.

• Single-Payer System: The French healthcare system operates under a single-payer model, where the government is the primary payer for healthcare services. The government collects funds through payroll taxes, income taxes, and other contributions, and reimburses healthcare providers directly. In the United States, the healthcare system is primarily based on a multi-payer model, with a combination of public and private insurance providers.

• Comprehensive Benefits: The French system provides comprehensive benefits, including coverage for hospital care, primary care, prescription drugs, maternity care, mental health services, and more. The benefits are standardized and provided to all residents. In the United States, the scope of benefits can vary widely depending on the insurance coverage, and many plans have restrictions or limitations on certain services.

• Cost-Sharing: The French system has cost-sharing mechanisms, but they are relatively low compared to the American system. Patients typically pay a percentage of the cost of their healthcare services, with caps on out-of-pocket expenses. In the United States, cost-sharing can be significant, with high deductibles, co-pays, and co-insurance, leading to potential financial burden for individuals.

• Primary Care Emphasis: The French system places a strong emphasis on primary care as the foundation of the healthcare system. Patients have easy access to primary care physicians and are encouraged to seek care from them as a first point of contact. This helps to coordinate care, prevent unnecessary hospitalizations, and promote continuity of care. In the United States, primary care is often less emphasized, leading to fragmented care and reliance on emergency departments for non-urgent care.

• Health Outcomes: France consistently performs well in international rankings of healthcare system performance and health outcomes. The country has a higher life expectancy and lower infant mortality rates compared to the United States, despite spending a lower percentage of its GDP on healthcare.

It is important to note that both systems have their strengths and weaknesses, and there is ongoing debate about the best approach to providing healthcare. The French system emphasizes universal coverage, comprehensive benefits, and primary care, while the American system focuses more on private insurance, market competition, and individual choice.

 

The answer from ChatGPT confirmed what I already knew, but I wanted a little bit more specificity about life expectancy. So, I asked:

 

How does the French healthcare system differ in terms of outcomes and life expectancy?

 

ChatGPT:

 

The French healthcare system has been recognized for achieving positive outcomes and relatively high life expectancy compared to the United States. Here are some key differences and statistics related to outcomes and life expectancy in the French healthcare system:

• Life Expectancy: France consistently has a higher life expectancy compared to the United States. According to the World Bank, as of 2020, the life expectancy at birth in France was around 82.9 years for males and 86.9 years for females. In contrast, the life expectancy in the United States was approximately 76.1 years for males and 81.1 years for females.

• Infant Mortality: France has a lower infant mortality rate compared to the United States. The infant mortality rate in France is relatively low, with around 3.2 deaths per 1,000 live births (as of 2020). In the United States, the infant mortality rate is higher at approximately 5.4 deaths per 1,000 live births.

• Healthcare Spending: France achieves favorable outcomes while spending a lower percentage of its GDP on healthcare compared to the United States. According to the World Health Organization (WHO), France spent around 11.2% of its GDP on healthcare in 2019, while the United States spent approximately 17.7%.

• Access to Care: The French healthcare system provides universal access to care, ensuring that all residents have coverage and can access necessary healthcare services. This emphasis on access to care helps prevent or manage health conditions more effectively, potentially contributing to better outcomes and life expectancy.

• Primary Care and Preventive Services: The French system places a strong emphasis on primary care and preventive services, which can lead to early detection and management of health conditions. Accessible primary care, including regular check-ups and screenings, helps promote prevention, continuity of care, and timely interventions.

It’s worth noting that while the French healthcare system has achieved positive outcomes and higher life expectancy compared to the United States, healthcare systems are complex and influenced by various factors, including social determinants of health. Comparative analyses should consider multiple factors beyond the healthcare system itself, such as socioeconomic factors, lifestyle choices, and public health initiatives.

It’s also important to recognize that healthcare outcomes are influenced by various factors beyond the healthcare system, such as socioeconomic factors, lifestyle choices, and public health initiatives. Nonetheless, the French healthcare system’s emphasis on universal coverage, primary care, and preventive services has contributed to positive outcomes and higher life expectancy compared to the United States.

 

When we think about the social determinants of health we need to consider services and benefits beyond direct healthcare. So, I asked about other social programs that might improve the social determinants of health.

 

How do French social services differ from America’s?

 

ChatGPT:

 

The social services in France and the United States differ in several key aspects. Here are some of the main differences between the social service systems of the two countries:

• Universal Social Safety Net: France has a comprehensive social safety net that provides a wide range of benefits and services to its residents. The French social services are designed to ensure a certain level of protection and support for individuals and families, regardless of their income or employment status. In the United States, social services are more fragmented and often targeted towards specific populations or needs, and access to social services can vary depending on eligibility criteria.

• Healthcare: As mentioned earlier, the French healthcare system provides universal coverage and is characterized by a single-payer model. All residents have access to healthcare services, and the government plays a significant role in funding and regulating the system. In the United States, healthcare coverage is more fragmented, with a mix of private and public insurance options. Access to healthcare services is often tied to employment or specific insurance plans.

• Education: In France, education is highly valued, and the education system is comprehensive and centralized. The government provides free education from pre-school through university, including vocational and technical training. In the United States, education is largely decentralized, with public schools funded by local taxes and a mix of public and private higher education institutions. The cost of education can vary significantly, and student loans are often required to finance higher education.

• Social Welfare Programs: France has an extensive social welfare system that includes various benefits and services to support individuals and families in need. This includes unemployment benefits, family allowances, housing assistance, and income support programs. In the United States, social welfare programs exist but are generally more limited and means-tested. Programs such as Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Medicaid provide assistance to eligible individuals and families, but the scope and coverage may vary across states.

• Labor Protections: France has robust labor protections, including strong worker rights, collective bargaining, and generous leave policies. French workers enjoy longer annual leave, shorter workweeks, and more extensive social security protections compared to the United States. In the U.S., labor protections and regulations are generally less comprehensive, and employment benefits and conditions can vary widely across different industries and states.

[As you probably know, the retirement age just went up from 62 to 64.]

It is important to note that the social service systems of both countries have their strengths and weaknesses and are shaped by historical, cultural, and political factors. Each system reflects different approaches to addressing social needs and supporting the well-being of their populations.

 

Where does France get the money it needs? Clearly, if you are spending only 11% of GDP on healthcare there is a lot of money available for other social services, but I did hear people talking about their tax load. So I asked:

 

How do taxes vary between America and France?

 

ChatGPT:

 

Taxes vary significantly between the United States and France. Here are some key differences in tax systems between the two countries:

• Tax Rates: France generally has higher tax rates compared to the United States. France has a progressive income tax system with multiple tax brackets, ranging from around 11% to 45%. In the United States, the federal income tax system is also progressive, with tax rates ranging from 10% to 37%. However, it’s important to note that the overall tax burden can vary based on various factors such as income level, deductions, and credits.

• Social Security Contributions: In France, social security contributions are a significant part of the tax system. These contributions are used to fund social benefits, including healthcare, pensions, and unemployment insurance. Social security contributions are calculated based on income and are typically shared between employers and employees. In the United States, Social Security and Medicare taxes are withheld from employees’ paychecks to fund these programs, but the rates are lower compared to social security contributions in France.

• Value Added Tax (VAT): France, like many European countries, has a value-added tax (VAT) system. VAT is a consumption tax applied to most goods and services, and the rate can vary depending on the category of the goods or services. In France, the standard VAT rate is currently 20%, with reduced rates of 5.5% and 10% for certain products. The United States does not have a nationwide VAT but instead relies more on sales taxes imposed at the state and local levels, which can vary widely.

• Property Taxes: Property taxes in France can be relatively high, especially for owners of real estate. Property tax rates vary by location and are determined at the local level. In the United States, property taxes are also imposed at the local level, and rates vary across states and municipalities.

• Corporate Taxes: Corporate tax rates in France tend to be higher compared to the United States. In France, the standard corporate tax rate is currently 26.5%. In the United States, the federal corporate tax rate is 21%, although there may be additional state and local corporate taxes that apply.

It’s important to note that tax systems are complex and subject to change. The information provided here offers a general overview, but specific details and rates can vary over time and depending on individual circumstances. It is always advisable to consult with tax professionals or refer to official sources for the most accurate and up-to-date information regarding taxes in each country.

 

I had other questions, but the answers were predictable and this letter is getting longer. I was impressed that the French seem to have what Bernie Sanders was suggesting for America. Taxes are higher, but the quality of healthcare and life, in general, was better for more people. Corporations and the rich pay more. My guess is that there are also not as many very high-paid specialists. It seems that it is about the collective choices we make. As Matthew Desmond has contended recently in his new book, Poverty, By America, and as Dr. Martin Luther King, Jr. contended almost sixty years ago, there is no justification for poverty in America. If we wanted to, we could do better than France and would also enjoy our own better version of “Liberté, Egalité, Fraternité.”

 

D-Day was 79 Years Ago 

 

This coming Tuesday, June 6, will be the 79th anniversary of the landing of the Allied Forces on the beaches of Normandy on “D-Day” which began the push to free France and Europe from the Nazis. Today’s header was taken at the American cemetery that sits above Omaha Beach in Normandy where there are over 9,000 graves of American soldiers and a wall with the names of more than 1,400 who are missing and presumed to have been killed. It is easy to read history and intellectually process what happened. It is another thing altogether to stand on a battlefield or in a cemetery and feel the presence of all of those who served and died for our shared ideals. 

 

I was told that at the request of families more than fifty percent of those who died in “Operation Overlord” were taken back home to be buried. It is a staggering site to see so many graves and realize that there were more than twice as many who died and that most of them were men who were in their teens and early twenties. D-Day was the largest invasion from the sea and air ever to occur in history. 

 

I was particularly interested in going to Normandy during my trip to France because my father’s older brother was part of the invasion. He was a sergeant in the 507th Parachute Infantry Battalion of the 82nd Airborne. On the night before the landing on the beach, he and 2000 other members of the “507” parachuted in behind Omaha Beach with the objective of securing the road and the bridges out of Omaha Beach that led to the port at Cherbourg. Their mission lasted just over a month. Only about 700 of the 2000 men who jumped into Normandy boarded the boat back to England where they would prepare for their next conflict at the Battle of the Bulge. My uncle was a participant in the Battle for the La Fière Bridge over the Merderet River which was “probably the bloodiest small unit struggle in the experience of American arms.” It is a very small bridge over a very small river as you can see in the picture. It is amazing that it took three days and almost 300 American lives to secure this very small but important bridge and the causeway from it across wetlands. 

 

 

My uncle was awarded a Bronze Star for exposing himself to enemy fire to retrieve critical communications equipment. During the fighting, he took over the command responsibilities of his squad after their lieutenant was killed. Over all of his experience in World War II, he was awarded three Bronze Stars and a Purple Heart. I spent a lot of time with him while I was a child, but I did not ever hear him talk about his experiences in World War II although I do remember him showing me the scars from the wounds he received from a German hand grenade. He died of colon cancer in 1969, and I did not learn of his participation on D-Day or of his commendations until more than thirty years after his death when I discovered the commendation in a box at my father’s home. 

 

My uncle and most of the participants of D-Day are now gone, but they gave all of us a great gift and the opportunity to continue to pursue “Liberté, Egalité, Fraternité” in better health. We owe them all great respect.

Be well,

Gene