Showing posts with label relocation. Show all posts
Showing posts with label relocation. Show all posts
Friday, March 28, 2008
Becoming a resident of France?
Legal Living in France
By Melissa Schulz
It took me six months to figure out the appropriate steps to take to live in France legally. The options are: finding a French employer who will arrange a visa, marrying a French citizen, joining the Foreign Legion, or becoming a student. The last option seemed to be the easiest and less emotionally exhausting.
All you have to do is sign up at one of the French for foreigners schools in Paris recognized by the French government (below), present your registration card at the French consulate in your home state, and get your student visa. All the schools offer programs to suit your level and needs, and some offer aid with the paperwork and housing. Request catalogues from each school and review them carefully before making a decision. (The Sorbonne is the most popular and least personal; it is also least expensive.)
After deciding on the school, you can register by phone, email, or fax. If you are in France, go directly to the school and preregister, then obtain your visa back in America. You must sign up for at least 20 hours of French a week to apply for a visa. Sign up for one year if you want a long-term student visa. Depending upon the school, you may have the option of making payments instead of paying all fees at once.
The next step is to go to the French consulate in your state of residence with all the necessary papers. The documents you will need vary from state to state, so check your local consulate web site.
Once in France, the first thing you need to do is get your Carte de Sejour at the police prefecture. Take with you to the prefecture: your final registration at the school of your choice (which you receive after taking your placement test), proof of payment of tuition, and proof of health insurance. If you are over 28, you have to get private coverage, which you can buy in France or America. Look in Fusac, www.fusac.fr a journal for English-speaking residents in France, and carefully compare prices. Take your insurance ID card, proof of residence, and proof of financial support to your local prefecture. The required documents vary, so ask your school to help you with the process. If you have the option, bring a French person with you.
Once you have your Carte de Sejour and you are legal you can open a bank account, get a mobile phone, and find part-time employment more easily. Try to start the process at least two months in advance of your departure. The peace of mind is worth the pain.
French Schools for Foreigners
Institut Catholique de Paris, 12 Rue Cassette, 75006 Paris; 011-33-01-44-39-52-68, fax 011-33-01-44-39-52-09; ilcf@icp.fr, www.icp.fr.
La Sorbonne, 47 rue des Ecoles, 75005 Paris; 011-33-01-40-46-22-11, fax 011-33-01-40-46-32-29; ccfs@paris4.sorbonne.fr, www.fle.fr/sorbonne. Cost per semester (20 hours a week for 12 weeks):
Alliance Francaise, 101 Blvd. Raspail, 75270 Paris; 011-01-42-84-90-00; info@alliancefr.org, www.alliancefr.org.
Basic residency rules for France
ALTHOUGH Johnny Halliday may have fled to Switzerland to dodge the French tax authorities, it is not an option open to many.
So issues concerning tax are likely to be high up on many people’s agendas when they are thinking about a move to France.
And the biggest factor that will decide how the tax office will treat you will be where you are considered resident.
An individual, whether a French or foreign national, is resident according to the French tax code if:
- You have a permanent home or principal place of sejour in France.
- You spend more than 183 days in France during a calendar year or spend more time in France that any other country.
- You carry out an occupation or are employed in France, except where this is incidental to a foreign activity.
- Your centre of economic interest is in France.
So if you fall into one of these brackets you are considered French resident and will pay taxes on your worldwide income.
But if you are outside, then you are considered non-resident and would pay taxes only on your French source income.
The tax authorities will decide your status at first and you are allowed to appeal if you do not agree with their decision.
But it can be seen that the rules have nothing to do with visas, passports, property ownership – you could be renting and be considered French resident for tax purposes.
If you have decided to move to France permanently then you should contact the tax authorities in your current country.
They may ask you to provide evidence that you are no longer resident, for example, in the UK the Inland Revenue ask if you have taken steps to acquire accommodation abroad.
It is possible that you may receive a tax refund but also you affairs will be tied off, ready to be set-up abroad.
However, it could occur that you fall between two stools and this is where the double taxation treaty between the UK and France comes in.
France also has taxation treaties with all other EU states as well as the USA, Australia, Canada and around 70 other countries.
But what the agreements ensure is that income that has already been taxed in one country is not liable to tax in another.
For example, pensions received from the UK, except for government pensions, will be taxed in France and not in the UK.
Residency and double taxation treaties are complex affairs and professional advice should be sought – but it is an important consideration.
A useful starting point is the Inland Revenue website:
Residents and non-residents - Liability to tax in the United Kingdom or Tax when living abroad.
By Craig McGinty on January 31, 2007, admin. In Property | Site RSS feed | Free newsletter
E-mail to a friend | Add to del.icio.us | Digg this | StumbleUpon | Listen to article
More: « Paris to adopt bike scheme | Home | Holiday home website tips »
Comments
Thanks so much for this post, I've been wondering about this since I moved here about a yr ago! The tax issue had to be resolved eventually & I'm glad to have found out certain things from your post.
Posted by: shannon | 7 Feb 2007 21:44:20
Hi Shannon, glad the article has helped out - at least getting your tax straight is one less worry.
All the best, Craig
Posted by: Craig McGinty | 8 Feb 2007 21:31:34
Canadian Resident dies and he has his RRIF benificiary his sister in UK. What are the taxes of the RRIF and who has to pay for it. Is it the estate or the benificiary. What are the witholding taxes in Canada. In the treaty it says that we can keep up to 43% witholding taxes in Canada and send the rest to UK. Nobody seems to know the right answer. We have been in touch with Ernest & Yound the biggest accounting firm in Vancouver and they don't have a clue about it. We have 3 lawyers working on this case and we don't have any definite answer. We are sure that this has happened before and how the accountants and the lawyers have delt with it. Please help, we are frustrated and don't know whom else to speak to. The Revenue Canada tells us that we have to hold the taxes in Canada but the accountants and the lawyers are doubtful about it.
Posted by: Heidi Baloun | 9 Mar 2007 21:20:27
I wonder if anyone can help me find out some information on becoming a french resident.
I am 2 years off retirement age, own a building project in france and work as a carer in England. I work for an agency so I pay my own tax, in other words I'm self employed. I would like to become a french resident this year and comute from time to time to carry on the work I'm doing in England.
Questions I'm looking for answeres to are:-
If I declare my earnings in france for tax purposes, would I have to pay social charges.-Equivelent to Nat. Ins. contributions? and is this alot mor than I pay in England?
Also would I be entitled to an E106?
Sophia
Posted by: Sophia Lee | 16 Jan 2008 15:48:52
Hi Sophia
If you are considered French resident then you would be included in their taxation system, so would be asked to pay social charges.
Contributions are higher than the UK, although the overall tax take is not that different, and I'm sure people would say that the services you receive are much better.
As for the E106 that only applies to people not working who would be entitled to Incapacity Benefit, and is for a limited period, more here:
http://www.dwp.gov.uk/international/sa29/medical_06.asp
So if you were paying into the system as self-employed then you would receive health cover as normal, and upon retirement receive cover as if you were in the UK.
I'd take a look over the Department of Work and Pensions website and give them a call.
Hope this helps
Craig
By Melissa Schulz
It took me six months to figure out the appropriate steps to take to live in France legally. The options are: finding a French employer who will arrange a visa, marrying a French citizen, joining the Foreign Legion, or becoming a student. The last option seemed to be the easiest and less emotionally exhausting.
All you have to do is sign up at one of the French for foreigners schools in Paris recognized by the French government (below), present your registration card at the French consulate in your home state, and get your student visa. All the schools offer programs to suit your level and needs, and some offer aid with the paperwork and housing. Request catalogues from each school and review them carefully before making a decision. (The Sorbonne is the most popular and least personal; it is also least expensive.)
After deciding on the school, you can register by phone, email, or fax. If you are in France, go directly to the school and preregister, then obtain your visa back in America. You must sign up for at least 20 hours of French a week to apply for a visa. Sign up for one year if you want a long-term student visa. Depending upon the school, you may have the option of making payments instead of paying all fees at once.
The next step is to go to the French consulate in your state of residence with all the necessary papers. The documents you will need vary from state to state, so check your local consulate web site.
Once in France, the first thing you need to do is get your Carte de Sejour at the police prefecture. Take with you to the prefecture: your final registration at the school of your choice (which you receive after taking your placement test), proof of payment of tuition, and proof of health insurance. If you are over 28, you have to get private coverage, which you can buy in France or America. Look in Fusac, www.fusac.fr a journal for English-speaking residents in France, and carefully compare prices. Take your insurance ID card, proof of residence, and proof of financial support to your local prefecture. The required documents vary, so ask your school to help you with the process. If you have the option, bring a French person with you.
Once you have your Carte de Sejour and you are legal you can open a bank account, get a mobile phone, and find part-time employment more easily. Try to start the process at least two months in advance of your departure. The peace of mind is worth the pain.
French Schools for Foreigners
Institut Catholique de Paris, 12 Rue Cassette, 75006 Paris; 011-33-01-44-39-52-68, fax 011-33-01-44-39-52-09; ilcf@icp.fr, www.icp.fr.
La Sorbonne, 47 rue des Ecoles, 75005 Paris; 011-33-01-40-46-22-11, fax 011-33-01-40-46-32-29; ccfs@paris4.sorbonne.fr, www.fle.fr/sorbonne. Cost per semester (20 hours a week for 12 weeks):
Alliance Francaise, 101 Blvd. Raspail, 75270 Paris; 011-01-42-84-90-00; info@alliancefr.org, www.alliancefr.org.
Basic residency rules for France
ALTHOUGH Johnny Halliday may have fled to Switzerland to dodge the French tax authorities, it is not an option open to many.
So issues concerning tax are likely to be high up on many people’s agendas when they are thinking about a move to France.
And the biggest factor that will decide how the tax office will treat you will be where you are considered resident.
An individual, whether a French or foreign national, is resident according to the French tax code if:
- You have a permanent home or principal place of sejour in France.
- You spend more than 183 days in France during a calendar year or spend more time in France that any other country.
- You carry out an occupation or are employed in France, except where this is incidental to a foreign activity.
- Your centre of economic interest is in France.
So if you fall into one of these brackets you are considered French resident and will pay taxes on your worldwide income.
But if you are outside, then you are considered non-resident and would pay taxes only on your French source income.
The tax authorities will decide your status at first and you are allowed to appeal if you do not agree with their decision.
But it can be seen that the rules have nothing to do with visas, passports, property ownership – you could be renting and be considered French resident for tax purposes.
If you have decided to move to France permanently then you should contact the tax authorities in your current country.
They may ask you to provide evidence that you are no longer resident, for example, in the UK the Inland Revenue ask if you have taken steps to acquire accommodation abroad.
It is possible that you may receive a tax refund but also you affairs will be tied off, ready to be set-up abroad.
However, it could occur that you fall between two stools and this is where the double taxation treaty between the UK and France comes in.
France also has taxation treaties with all other EU states as well as the USA, Australia, Canada and around 70 other countries.
But what the agreements ensure is that income that has already been taxed in one country is not liable to tax in another.
For example, pensions received from the UK, except for government pensions, will be taxed in France and not in the UK.
Residency and double taxation treaties are complex affairs and professional advice should be sought – but it is an important consideration.
A useful starting point is the Inland Revenue website:
Residents and non-residents - Liability to tax in the United Kingdom or Tax when living abroad.
By Craig McGinty on January 31, 2007, admin. In Property | Site RSS feed | Free newsletter
E-mail to a friend | Add to del.icio.us | Digg this | StumbleUpon | Listen to article
More: « Paris to adopt bike scheme | Home | Holiday home website tips »
Comments
Thanks so much for this post, I've been wondering about this since I moved here about a yr ago! The tax issue had to be resolved eventually & I'm glad to have found out certain things from your post.
Posted by: shannon | 7 Feb 2007 21:44:20
Hi Shannon, glad the article has helped out - at least getting your tax straight is one less worry.
All the best, Craig
Posted by: Craig McGinty | 8 Feb 2007 21:31:34
Canadian Resident dies and he has his RRIF benificiary his sister in UK. What are the taxes of the RRIF and who has to pay for it. Is it the estate or the benificiary. What are the witholding taxes in Canada. In the treaty it says that we can keep up to 43% witholding taxes in Canada and send the rest to UK. Nobody seems to know the right answer. We have been in touch with Ernest & Yound the biggest accounting firm in Vancouver and they don't have a clue about it. We have 3 lawyers working on this case and we don't have any definite answer. We are sure that this has happened before and how the accountants and the lawyers have delt with it. Please help, we are frustrated and don't know whom else to speak to. The Revenue Canada tells us that we have to hold the taxes in Canada but the accountants and the lawyers are doubtful about it.
Posted by: Heidi Baloun | 9 Mar 2007 21:20:27
I wonder if anyone can help me find out some information on becoming a french resident.
I am 2 years off retirement age, own a building project in france and work as a carer in England. I work for an agency so I pay my own tax, in other words I'm self employed. I would like to become a french resident this year and comute from time to time to carry on the work I'm doing in England.
Questions I'm looking for answeres to are:-
If I declare my earnings in france for tax purposes, would I have to pay social charges.-Equivelent to Nat. Ins. contributions? and is this alot mor than I pay in England?
Also would I be entitled to an E106?
Sophia
Posted by: Sophia Lee | 16 Jan 2008 15:48:52
Hi Sophia
If you are considered French resident then you would be included in their taxation system, so would be asked to pay social charges.
Contributions are higher than the UK, although the overall tax take is not that different, and I'm sure people would say that the services you receive are much better.
As for the E106 that only applies to people not working who would be entitled to Incapacity Benefit, and is for a limited period, more here:
http://www.dwp.gov.uk/international/sa29/medical_06.asp
So if you were paying into the system as self-employed then you would receive health cover as normal, and upon retirement receive cover as if you were in the UK.
I'd take a look over the Department of Work and Pensions website and give them a call.
Hope this helps
Craig
The French Health Care System
Doctors still make house calls? Click here
The French Health Care System
Article Date: 27 Jun 2004 - 15:00 PST
-- HEALTH INSURANCE AND ACCESS TO CARE --
To best understand how the French health care system works, I think it is best to begin with a look at the French health insurance system.
First of all, all legal residents of France are covered by public health insurance, which is one of the social security system's entitlement programs. The public health insurance program was set up in 1945 and coverage was gradually expanded over the years to all legal residents: indeed, until January 2000, a small part of the population was still denied access to the public health insurance.
The funding and benefits of the French public health insurance system (PHIS), much like Germany's, were originally based on professional activity. The main fund covers 80% of the population. Two other funds cover the self-employed and agricultural workers.
Once varying depending on the fund, disparate reimbursement rates were replaced by uniform rates. The funds are financed by employer and employee contributions, as well as personal income taxes. The latter's share of the financing has been ever-increasing in order to:
� compensate for the relative decrease of wage income,
� limit price distortions on the labor market,
� and more fairly distribute the system's financing among citizens.
Most health insurance funds are private entities which are jointly managed by employers' federations and union federations, under the State's supervision. The joint labor/management handling has always sown discord within the funds' boards, as well as between the boards and the State.
As a consequence, the responsibilities of the various actors in the system are not always shared in the most coherent manner.
For example, the parliament's budget provisions determine how much public money will go to health expenditure, the cabinet decides reimbursement rates and sets the amount of contributions earmarked for the funds, while the funds themselves negotiate with health care professions to set tariffs designed to ensure the system operates at the breakeven point. Responsibilities are frequently redefined, but never to satisfaction of all involved.
1 Permanent Working Group of European Junior Doctors, October 2001.
2 1 rue Paul C�zanne 75008 Paris France. couffinhal@irdes.fr, www..fr, Tel: 33(0)153934318.
The views expressed here are those of the author, and they do not necessarily reflect the views of the IRDES.
Agn�s Couffinhal - IRDES October 2001 2
The public health insurance system covers about 75% of total health expenditures. Half of the outstanding amount is covered by patients' out-of-pocket payments and the other half is paid by private health insurance companies. These supplementary health insurance policies can be taken out by individuals or groups.
About 85% of the population own such policies.
An important peculiarity of the French PHIS is that the funds cover a very wide range of goods and services, including for example, stays in thermal spas.
In the hope of curbing consumption and expenditures, copayments were implemented and have increased over time. These copayments are relatively high for many out-patient services.
For example, patients must pay 30% of Social security's tariff for a physician's visit, moreover, roughly 40% of specialists and 15% of GPs are allowed to charge more than the tariff. Copayments are also high for dental prostheses and eye-ware. This tended to deter the poorest citizens (few of whom had supplementary insurance) from seeking care. Concerns grew over the system's inequity.
In January 2000, a means-tested, public supplementary insurance program called CMU (Couverture maladie universelle) was implemented to ensure the poor access to health care.
For those whose income is below a certain threshold (about 10% of the population is eligible), this insurance covers all public copayments and offers lumps-sum reimbursements for glasses and dental prostheses. Health professionals are not allowed to charge more than the public tariff or the lump-sum for CMU beneficiaries, which means that in theory, access to care is free of charge.
In passing, I'd like to mention that many experts advocate a change in the way health insurance covers care. They think it would be more efficient and equitable to clearly define a set of indispensable goods and services which should be available to everyone and which should be 100% publicly financed. The remaining goods and services would be available to those who desire and can afford them, with or without relying on private insurance.
To close this aside on access to care, I'd like to add that, as far as I know, France is the only country in which access to care is unlimited: patients can see as many physicians as often as they like. Patients do not need referrals to see specialists, and in general, there is no gatekeeping system of any kind. This may partially account for the World Health Organization's high ranking of France's health care system last year: the rating system emphasized the system's responsiveness (a measure of patients' freedom and flexibility), a quality the French system provides, undeniably at the expense of overall efficiency.
Agn�s Couffinhal - IRDES October 2001 3
-- THE STATE'S ROLE --
1. The State decides on what care is to be reimbursed and to what extent, defines the responsibilities of the various actors, and ensures that the entire population has access to care.
2. The State defends patients' rights, drafting and enforcing relevant policy. The State is thus responsible for safety within the health system. The disaster and subsequent cover-up of the contamination of the nation's hemoglobin supply with HIV-tainted blood resulted in the revamping of public health policy. New agencies were created to oversee safety measures concerning the nation's blood supply, organ donor programs, food, and medical goods and services. The recent handling of the mad cow crisis indicates that these changes have improved public safety.
3. The State is also in charge of planning. Health authorities decide on the size and number of hospitals, as well as the amount and allocation of highly technical equipment (MRI, CTscans...). It organizes the supply of specialized wards (transplants, neurosurgery...) and ensures the provision of care at all times, like emergency rooms.
Since 1991, some of the planning has taken place at the regional level. Indeed, more and more policy-making and negotiation are undertaken at the regional level, and this tendency is likely to continue in the coming years.
-- THE CARE SUPPLY HOSPITALS --
In France, hospitals have always been the core of the health care system. This probably accounts for the extremely specialized, technical, curative nature of our care, arguably to the detriment of prevention and community services.
The number of hospital beds has decreased over time: it currently stands at 8.4 per 1,000 inhabitants, which is close to the European average. Hospitals can be roughly divided into two categories: public, and private for-profit.
� The public sector represents about 65% of the beds. Public hospitals have specific obligations such as ensuring the continuity of care, teaching, and training. They receive a budget which is largely based on a historical basis.
� Private for-profit hospitals concentrate on surgical procedures and rely mostly on fee-forservice remuneration for their funding.
A uniform hospital information system has been implemented to monitor the various establishments activity. Gradually, all public and private establishments are to switch to DRG payment systems.
Agn�s Couffinhal - IRDES October 2001 4
-- HEALTH PROFESSIONALS --
Of the many types of health professionals, I would like to focus on physicians, as they play a key political role in the system. There are currently about 200,800 physicians licensed to practice in France. In the last thirty years the number of physicians has tripled, but the rate of increase is now very slight. Indeed, since 1971, the Ministry of Health has limited the number of medical students, a measure which, along with the retirement of currently active doctors, will result in a decrease in the number of physicians in the near future.
Half of the physicians are specialists.
In France, physicians (and other professionals) generally work in two kinds of environments: public hospitals and private practices. 25% of physicians work in public hospitals (another 11% work in other types of public establishments). They are in essence public servants and paid an amount that is fixed by the government. Today, many physicians feel that the prestige of working in a hospital does not compensate for the trying working conditions. 56% of physicians work in private practices3, and are paid on a fee-for-service basis.
The relative weight of the procedures is set by experts and the prices are negotiated by physicians' unions and public health insurance funds4.
Since the creation of Social Security, the relationship between private practice physicians and the State and public insurance funds has always been strained. A contract (convention) which sets the general regulatory framework and the remuneration of the profession is supposed to be signed every 5 years by physicians unions. The first one was signed in 1971, 26 years after public health insurance was created. Subsequent conventions allowed some physicians to charge more than social security tariffs (1980), limited this right (1990) and implemented official medical practice guidelines (RMO, R�f�rences m�dicales opposables) in 1993.
The current situation is particularly strained: negotiations between doctors' unions and the funds have stalled, leaving the specialists without a convention and isolating the GP union which signed a convention in 1998. The root of the problem is that private practice physicians are strongly opposed to the setting caps on outpatient expenditures. They have always had a great deal of freedom over where they set up shop, how they practice, and what they prescribe (compared to their counterparts in other countries). Yet the bulk of their income is paid by public funds. This contradiction has become more glaring as the concerns about soaring health expenditures grew.
The French Health Care System
Article Date: 27 Jun 2004 - 15:00 PST
-- HEALTH INSURANCE AND ACCESS TO CARE --
To best understand how the French health care system works, I think it is best to begin with a look at the French health insurance system.
First of all, all legal residents of France are covered by public health insurance, which is one of the social security system's entitlement programs. The public health insurance program was set up in 1945 and coverage was gradually expanded over the years to all legal residents: indeed, until January 2000, a small part of the population was still denied access to the public health insurance.
The funding and benefits of the French public health insurance system (PHIS), much like Germany's, were originally based on professional activity. The main fund covers 80% of the population. Two other funds cover the self-employed and agricultural workers.
Once varying depending on the fund, disparate reimbursement rates were replaced by uniform rates. The funds are financed by employer and employee contributions, as well as personal income taxes. The latter's share of the financing has been ever-increasing in order to:
� compensate for the relative decrease of wage income,
� limit price distortions on the labor market,
� and more fairly distribute the system's financing among citizens.
Most health insurance funds are private entities which are jointly managed by employers' federations and union federations, under the State's supervision. The joint labor/management handling has always sown discord within the funds' boards, as well as between the boards and the State.
As a consequence, the responsibilities of the various actors in the system are not always shared in the most coherent manner.
For example, the parliament's budget provisions determine how much public money will go to health expenditure, the cabinet decides reimbursement rates and sets the amount of contributions earmarked for the funds, while the funds themselves negotiate with health care professions to set tariffs designed to ensure the system operates at the breakeven point. Responsibilities are frequently redefined, but never to satisfaction of all involved.
1 Permanent Working Group of European Junior Doctors, October 2001.
2 1 rue Paul C�zanne 75008 Paris France. couffinhal@irdes.fr, www..fr, Tel: 33(0)153934318.
The views expressed here are those of the author, and they do not necessarily reflect the views of the IRDES.
Agn�s Couffinhal - IRDES October 2001 2
The public health insurance system covers about 75% of total health expenditures. Half of the outstanding amount is covered by patients' out-of-pocket payments and the other half is paid by private health insurance companies. These supplementary health insurance policies can be taken out by individuals or groups.
About 85% of the population own such policies.
An important peculiarity of the French PHIS is that the funds cover a very wide range of goods and services, including for example, stays in thermal spas.
In the hope of curbing consumption and expenditures, copayments were implemented and have increased over time. These copayments are relatively high for many out-patient services.
For example, patients must pay 30% of Social security's tariff for a physician's visit, moreover, roughly 40% of specialists and 15% of GPs are allowed to charge more than the tariff. Copayments are also high for dental prostheses and eye-ware. This tended to deter the poorest citizens (few of whom had supplementary insurance) from seeking care. Concerns grew over the system's inequity.
In January 2000, a means-tested, public supplementary insurance program called CMU (Couverture maladie universelle) was implemented to ensure the poor access to health care.
For those whose income is below a certain threshold (about 10% of the population is eligible), this insurance covers all public copayments and offers lumps-sum reimbursements for glasses and dental prostheses. Health professionals are not allowed to charge more than the public tariff or the lump-sum for CMU beneficiaries, which means that in theory, access to care is free of charge.
In passing, I'd like to mention that many experts advocate a change in the way health insurance covers care. They think it would be more efficient and equitable to clearly define a set of indispensable goods and services which should be available to everyone and which should be 100% publicly financed. The remaining goods and services would be available to those who desire and can afford them, with or without relying on private insurance.
To close this aside on access to care, I'd like to add that, as far as I know, France is the only country in which access to care is unlimited: patients can see as many physicians as often as they like. Patients do not need referrals to see specialists, and in general, there is no gatekeeping system of any kind. This may partially account for the World Health Organization's high ranking of France's health care system last year: the rating system emphasized the system's responsiveness (a measure of patients' freedom and flexibility), a quality the French system provides, undeniably at the expense of overall efficiency.
Agn�s Couffinhal - IRDES October 2001 3
-- THE STATE'S ROLE --
1. The State decides on what care is to be reimbursed and to what extent, defines the responsibilities of the various actors, and ensures that the entire population has access to care.
2. The State defends patients' rights, drafting and enforcing relevant policy. The State is thus responsible for safety within the health system. The disaster and subsequent cover-up of the contamination of the nation's hemoglobin supply with HIV-tainted blood resulted in the revamping of public health policy. New agencies were created to oversee safety measures concerning the nation's blood supply, organ donor programs, food, and medical goods and services. The recent handling of the mad cow crisis indicates that these changes have improved public safety.
3. The State is also in charge of planning. Health authorities decide on the size and number of hospitals, as well as the amount and allocation of highly technical equipment (MRI, CTscans...). It organizes the supply of specialized wards (transplants, neurosurgery...) and ensures the provision of care at all times, like emergency rooms.
Since 1991, some of the planning has taken place at the regional level. Indeed, more and more policy-making and negotiation are undertaken at the regional level, and this tendency is likely to continue in the coming years.
-- THE CARE SUPPLY HOSPITALS --
In France, hospitals have always been the core of the health care system. This probably accounts for the extremely specialized, technical, curative nature of our care, arguably to the detriment of prevention and community services.
The number of hospital beds has decreased over time: it currently stands at 8.4 per 1,000 inhabitants, which is close to the European average. Hospitals can be roughly divided into two categories: public, and private for-profit.
� The public sector represents about 65% of the beds. Public hospitals have specific obligations such as ensuring the continuity of care, teaching, and training. They receive a budget which is largely based on a historical basis.
� Private for-profit hospitals concentrate on surgical procedures and rely mostly on fee-forservice remuneration for their funding.
A uniform hospital information system has been implemented to monitor the various establishments activity. Gradually, all public and private establishments are to switch to DRG payment systems.
Agn�s Couffinhal - IRDES October 2001 4
-- HEALTH PROFESSIONALS --
Of the many types of health professionals, I would like to focus on physicians, as they play a key political role in the system. There are currently about 200,800 physicians licensed to practice in France. In the last thirty years the number of physicians has tripled, but the rate of increase is now very slight. Indeed, since 1971, the Ministry of Health has limited the number of medical students, a measure which, along with the retirement of currently active doctors, will result in a decrease in the number of physicians in the near future.
Half of the physicians are specialists.
In France, physicians (and other professionals) generally work in two kinds of environments: public hospitals and private practices. 25% of physicians work in public hospitals (another 11% work in other types of public establishments). They are in essence public servants and paid an amount that is fixed by the government. Today, many physicians feel that the prestige of working in a hospital does not compensate for the trying working conditions. 56% of physicians work in private practices3, and are paid on a fee-for-service basis.
The relative weight of the procedures is set by experts and the prices are negotiated by physicians' unions and public health insurance funds4.
Since the creation of Social Security, the relationship between private practice physicians and the State and public insurance funds has always been strained. A contract (convention) which sets the general regulatory framework and the remuneration of the profession is supposed to be signed every 5 years by physicians unions. The first one was signed in 1971, 26 years after public health insurance was created. Subsequent conventions allowed some physicians to charge more than social security tariffs (1980), limited this right (1990) and implemented official medical practice guidelines (RMO, R�f�rences m�dicales opposables) in 1993.
The current situation is particularly strained: negotiations between doctors' unions and the funds have stalled, leaving the specialists without a convention and isolating the GP union which signed a convention in 1998. The root of the problem is that private practice physicians are strongly opposed to the setting caps on outpatient expenditures. They have always had a great deal of freedom over where they set up shop, how they practice, and what they prescribe (compared to their counterparts in other countries). Yet the bulk of their income is paid by public funds. This contradiction has become more glaring as the concerns about soaring health expenditures grew.
ten myths about Canadian health care
February 8th, 2008 2:59 pm
10 Myths About Canadian Health Care, Busted
By Sara Robinson / AlterNet
2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning -- and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.
I'm both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I'm in a unique position to address the pros and cons of both systems first-hand. If we're going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.
To that end, here's the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they're made of.
1. Canada's health care system is "socialized medicine."
False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.
The proper term for this is "single-payer insurance." In talking to Americans about it, the better phrase is "Medicare for all."
2. Doctors are hurt financially by single-payer health care.
True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:
First, as noted, they don't have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.
Second, they don't have to spend several hours every day on the phone cajoling insurance company bean counters into doing the right thing by their patients. My doctor in California worked a 70-hour week: 35 hours seeing patients, and another 35 hours on the phone arguing with insurance companies. My Canadian doctor, on the other hand, works a 35-hour week, period. She files her invoices online, and the vast majority are simply paid -- quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren't interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). She gets her checks on time, sees her patients on schedule, takes Thursdays off, and gets home in time for dinner.
One unsurprising side effect of all this is that the doctors I see here are, to a person, more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don't realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don't operate under that stress, because they never have to fight those battles at all. Amazingly: they seem to enjoy their jobs.
Third: The average American medical student graduates $140,000 in hock. The average Canadian doctor's debt is roughly half that.
Finally, Canadian doctors pay lower malpractice insurance fees. When paying for health care constitutes a one of a family's major expenses, expectations tend to run very high. A doctor's mistake not only damages the body; it may very well throw a middle-class family permanently into the ranks of the working poor, and render the victim uninsurable for life. With so much at stake, it's no wonder people are quick to rush to court for redress.
Canadians are far less likely to sue in the first place, since they're not having to absorb devastating financial losses in addition to any physical losses when something goes awry. The cost of the damaging treatment will be covered. So will the cost of fixing it. And, no matter what happens, the victim will remain insured for life. When lawsuits do occur, the awards don't have to include coverage for future medical costs, which reduces the insurance company's liability.
3. Wait times in Canada are horrendous.
True and False again -- it depends on which province you live in, and what's wrong with you. Canada's health care system runs on federal guidelines that ensure uniform standards of care, but each territory and province administers its own program. Some provinces don't plan their facilities well enough; in those, you can have waits. Some do better. As a general rule, the farther north you live, the harder it is to get to care, simply because the doctors and hospitals are concentrated in the south. But that's just as true in any rural county in the U.S.
You can hear the bitching about it no matter where you live, though. The percentage of Canadians who'd consider giving up their beloved system consistently languishes in the single digits. A few years ago, a TV show asked Canadians to name the Greatest Canadian in history; and in a broad national consensus, they gave the honor to Tommy Douglas, the Saskatchewan premier who is considered the father of the country's health care system. (And no, it had nothing to do with the fact that he was also Kiefer Sutherland's grandfather.). In spite of that, though, grousing about health care is still unofficially Canada's third national sport after curling and hockey.
And for the country's newspapers, it's a prime watchdogging opportunity. Any little thing goes sideways at the local hospital, and it's on the front pages the next day. Those kinds of stories sell papers, because everyone is invested in that system and has a personal stake in how well it functions. The American system might benefit from this kind of constant scrutiny, because it's certainly one of the things that keeps the quality high. But it also makes people think it's far worse than it is.
Critics should be reminded that the American system is not exactly instant-on, either. When I lived in California, I had excellent insurance, and got my care through one of the best university-based systems in the nation. Yet I routinely had to wait anywhere from six to twelve weeks to get in to see a specialist. Non-emergency surgical waits could be anywhere from four weeks to four months. After two years in the BC system, I'm finding the experience to be pretty much comparable, and often better. The notable exception is MRIs, which were easy in California, but can take many months to get here. (It's the number one thing people go over the border for.) Other than that, urban Canadians get care about as fast as urban Americans do.
4. You have to wait forever to get a family doctor.
False for the vast majority of Canadians, but True for a few. Again, it all depends on where you live. I live in suburban Vancouver, and there are any number of first-rate GPs in my neighborhood who are taking new patients. If you don't have a working relationship with one, but need to see a doctor now, there are 24-hour urgent care clinics in most neighborhoods that will usually get you in and out on the minor stuff in under an hour.
It is, absolutely, harder to get to a doctor if you live out in a small town, or up in the territories. But that's just as true in the U.S. -- and in America, the government won't cover the airfare for rural folk to come down to the city for needed treatment, which all the provincial plans do.
5. You don't get to choose your own doctor.
Scurrilously False. Somebody, somewhere, is getting paid a lot of money to make this kind of stuff up. The cons love to scare the kids with stories about the government picking your doctor for you, and you don't get a choice. Be afraid! Be very afraid!
For the record: Canadians pick their own doctors, just like Americans do. And not only that: since it all pays the same, poor Canadians have exactly the same access to the country's top specialists that rich ones do.
6. Canada's care plan only covers the basics. You're still on your own for any extras, including prescription drugs. And you still have to pay for it.
True -- but not as big an issue as you might think. The province does charge a small monthly premium (ours is $108/month for a family of four) for the basic coverage. However, most people never even have to write that check: almost all employers pick up the tab for their employees' premiums as part of the standard benefits package; and the province covers it for people on public assistance or disability.
"The basics" covered by this plan include 100% of all doctor's fees, ambulance fares, tests, and everything that happens in a hospital -- in other words, the really big-ticket items that routinely drive American families into bankruptcy. In BC, it doesn't include "extras" like medical equipment, prescriptions, physical therapy or chiropractic care, dental, vision, and so on; and if you want a private or semi-private room with TV and phone, that costs extra (about what you'd pay for a room in a middling hotel). That other stuff does add up; but it's far easier to afford if you're not having to cover the big expenses, too. Furthermore: you can deduct any out-of-pocket health expenses you do have to pay off your income taxes. And, as every American knows by now, drugs aren't nearly as expensive here, either.
Filling the gap between the basics and the extras is the job of the country's remaining private health insurers. Since they're off the hook for the ruinously expensive big-ticket items that can put their own profits at risk, the insurance companies make a tidy business out of offering inexpensive policies that cover all those smaller, more predictable expenses. Top-quality add-on policies typically run in the ballpark of $75 per person in a family per month -- about $300 for a family of four -- if you're stuck buying an individual plan. Group plans are cheap enough that even small employers can afford to offer them as a routine benefit. An average working Canadian with employer-paid basic care and supplemental insurance gets free coverage equal to the best policies now only offered at a few of America's largest corporations. And that employer is probably only paying a couple hundred dollars a month to provide that benefit.
7. Canadian drugs are not the same.
More preposterious bogosity. They are exactly the same drugs, made by the same pharmaceutical companies, often in the same factories. The Canadian drug distribution system, however, has much tighter oversight; and pharmacies and pharmacists are more closely regulated. If there is a difference in Canadian drugs at all, they're actually likely to be safer.
Also: pharmacists here dispense what the doctors tell them to dispense, the first time, without moralizing. I know. It's amazing.
8. Publicly-funded programs will inevitably lead to rationed health care, particularly for the elderly.
False. And bogglingly so. The papers would have a field day if there was the barest hint that this might be true.
One of the things that constantly amazes me here is how well-cared-for the elderly and disabled you see on the streets here are. No, these people are not being thrown out on the curb. In fact, they live longer, healthier, and more productive lives because they're getting a constant level of care that ensures small things get treated before they become big problems.
The health care system also makes it easier on their caregiving adult children, who have more time to look in on Mom and take her on outings because they aren't working 60-hour weeks trying to hold onto a job that gives them insurance.
9. People won't be responsible for their own health if they're not being forced to pay for the consequences.
False. The philosophical basis of America's privatized health care system might best be characterized as medical Calvinism. It's fascinating to watch well-educated secularists who recoil at the Protestant obsession with personal virtue, prosperity as a cardinal sign of election by God, and total responsibility for one's own salvation turn into fire-eyed, moralizing True Believers when it comes to the subject of Taking Responsibility For One's Own Health.
They'll insist that health, like salvation, is entirely in our own hands. If you just have the character and self-discipline to stick to an abstemious regime of careful diet, clean living, and frequent sweat offerings to the Great Treadmill God, you'll never get sick. (Like all good theologies, there's even an unspoken promise of immortality: f you do it really really right, they imply, you might even live forever.) The virtuous Elect can be discerned by their svelte figures and low cholesterol numbers. From here, it's a short leap to the conviction that those who suffer from chronic conditions are victims of their own weaknesses, and simply getting what they deserve. Part of their punishment is being forced to pay for the expensive, heavily marketed pharmaceuticals needed to alleviate these avoidable illnesses. They can't complain. It was their own damned fault; and it's not our responsibility to pay for their sins. In fact, it's recently been suggested that they be shunned, lest they lead the virtuous into sin.
Of course, this is bad theology whether you're applying it to the state of one's soul or one's arteries. The fact is that bad genes, bad luck, and the ravages of age eventually take their toll on all of us -- even the most careful of us. The economics of the Canadian system reflect this very different philosophy: it's built on the belief that maintaining health is not an individual responsibility, but a collective one. Since none of us controls fate, the least we can do is be there for each other as our numbers come up.
This difference is expressed in a few different ways. First: Canadians tend to think of tending to one's health as one of your duties as a citizen. You do what's right because you don't want to take up space in the system, or put that burden on your fellow taxpayers. Second, "taking care of yourself" has a slightly expanded definition here, which includes a greater emphasis on public health. Canadians are serious about not coming to work if you're contagious, and seeing a doctor ASAP if you need to. Staying healthy includes not only diet and exercise; but also taking care to keep your germs to yourself, avoiding stress, and getting things treated while they're still small and cheap to fix.
Third, there's a somewhat larger awareness that stress leads to big-ticket illnesses -- and a somewhat lower cultural tolerance for employers who put people in high-stress situations. Nobody wants to pick up the tab for their greed. And finally, there's a generally greater acceptance on the part of both the elderly and their families that end-of-life heroics may be drawing resources away from people who might put them to better use. You can have them if you want them; but reasonable and compassionate people should be able to take the larger view.
The bottom line: When it comes to getting people to make healthy choices, appealing to their sense of the common good seems to work at least as well as Calvinist moralizing.
10. This all sounds great -- but the taxes to cover it are just unaffordable. And besides, isn't the system in bad financial shape?
False. On one hand, our annual Canadian tax bite runs about 10% higher than our U.S. taxes did. On the other, we're not paying out the equivalent of two new car payments every month to keep the family insured here. When you balance out the difference, we're actually money ahead. When you factor in the greatly increased social stability that follows when everybody's getting their necessary health care, the impact on our quality of life becomes even more signficant.
And True -- but only because this is a universal truth that we need to make our peace with. Yes, the provincial plans are always struggling. So is every single publicly-funded health care system in the world, including the VA and Medicare. There's always tension between what the users of the system want, and what the taxpayers are willing to pay. The balance of power ebbs and flows between them; but no matter where it lies at any given moment, at least one of the pair is always going to be at least somewhat unhappy.
But, as many of us know all too well, there's also constant tension between what patients want and what private insurers are willing to pay. At least when it's in government hands, we can demand some accountability. And my experience in Canada has convinced me that this accountability is what makes all the difference between the two systems.
It is true that Canada's system is not the same as the U.S. system. It's designed to deliver a somewhat different product, to a population that has somewhat different expectations. But the end result is that the vast majority of Canadians get the vast majority of what they need the vast majority of the time. It'll be a good day when when Americans can hold their heads high and proudly make that same declaration.
10 Myths About Canadian Health Care, Busted
By Sara Robinson / AlterNet
2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning -- and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.
I'm both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I'm in a unique position to address the pros and cons of both systems first-hand. If we're going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.
To that end, here's the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they're made of.
1. Canada's health care system is "socialized medicine."
False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.
The proper term for this is "single-payer insurance." In talking to Americans about it, the better phrase is "Medicare for all."
2. Doctors are hurt financially by single-payer health care.
True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:
First, as noted, they don't have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.
Second, they don't have to spend several hours every day on the phone cajoling insurance company bean counters into doing the right thing by their patients. My doctor in California worked a 70-hour week: 35 hours seeing patients, and another 35 hours on the phone arguing with insurance companies. My Canadian doctor, on the other hand, works a 35-hour week, period. She files her invoices online, and the vast majority are simply paid -- quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren't interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). She gets her checks on time, sees her patients on schedule, takes Thursdays off, and gets home in time for dinner.
One unsurprising side effect of all this is that the doctors I see here are, to a person, more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don't realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don't operate under that stress, because they never have to fight those battles at all. Amazingly: they seem to enjoy their jobs.
Third: The average American medical student graduates $140,000 in hock. The average Canadian doctor's debt is roughly half that.
Finally, Canadian doctors pay lower malpractice insurance fees. When paying for health care constitutes a one of a family's major expenses, expectations tend to run very high. A doctor's mistake not only damages the body; it may very well throw a middle-class family permanently into the ranks of the working poor, and render the victim uninsurable for life. With so much at stake, it's no wonder people are quick to rush to court for redress.
Canadians are far less likely to sue in the first place, since they're not having to absorb devastating financial losses in addition to any physical losses when something goes awry. The cost of the damaging treatment will be covered. So will the cost of fixing it. And, no matter what happens, the victim will remain insured for life. When lawsuits do occur, the awards don't have to include coverage for future medical costs, which reduces the insurance company's liability.
3. Wait times in Canada are horrendous.
True and False again -- it depends on which province you live in, and what's wrong with you. Canada's health care system runs on federal guidelines that ensure uniform standards of care, but each territory and province administers its own program. Some provinces don't plan their facilities well enough; in those, you can have waits. Some do better. As a general rule, the farther north you live, the harder it is to get to care, simply because the doctors and hospitals are concentrated in the south. But that's just as true in any rural county in the U.S.
You can hear the bitching about it no matter where you live, though. The percentage of Canadians who'd consider giving up their beloved system consistently languishes in the single digits. A few years ago, a TV show asked Canadians to name the Greatest Canadian in history; and in a broad national consensus, they gave the honor to Tommy Douglas, the Saskatchewan premier who is considered the father of the country's health care system. (And no, it had nothing to do with the fact that he was also Kiefer Sutherland's grandfather.). In spite of that, though, grousing about health care is still unofficially Canada's third national sport after curling and hockey.
And for the country's newspapers, it's a prime watchdogging opportunity. Any little thing goes sideways at the local hospital, and it's on the front pages the next day. Those kinds of stories sell papers, because everyone is invested in that system and has a personal stake in how well it functions. The American system might benefit from this kind of constant scrutiny, because it's certainly one of the things that keeps the quality high. But it also makes people think it's far worse than it is.
Critics should be reminded that the American system is not exactly instant-on, either. When I lived in California, I had excellent insurance, and got my care through one of the best university-based systems in the nation. Yet I routinely had to wait anywhere from six to twelve weeks to get in to see a specialist. Non-emergency surgical waits could be anywhere from four weeks to four months. After two years in the BC system, I'm finding the experience to be pretty much comparable, and often better. The notable exception is MRIs, which were easy in California, but can take many months to get here. (It's the number one thing people go over the border for.) Other than that, urban Canadians get care about as fast as urban Americans do.
4. You have to wait forever to get a family doctor.
False for the vast majority of Canadians, but True for a few. Again, it all depends on where you live. I live in suburban Vancouver, and there are any number of first-rate GPs in my neighborhood who are taking new patients. If you don't have a working relationship with one, but need to see a doctor now, there are 24-hour urgent care clinics in most neighborhoods that will usually get you in and out on the minor stuff in under an hour.
It is, absolutely, harder to get to a doctor if you live out in a small town, or up in the territories. But that's just as true in the U.S. -- and in America, the government won't cover the airfare for rural folk to come down to the city for needed treatment, which all the provincial plans do.
5. You don't get to choose your own doctor.
Scurrilously False. Somebody, somewhere, is getting paid a lot of money to make this kind of stuff up. The cons love to scare the kids with stories about the government picking your doctor for you, and you don't get a choice. Be afraid! Be very afraid!
For the record: Canadians pick their own doctors, just like Americans do. And not only that: since it all pays the same, poor Canadians have exactly the same access to the country's top specialists that rich ones do.
6. Canada's care plan only covers the basics. You're still on your own for any extras, including prescription drugs. And you still have to pay for it.
True -- but not as big an issue as you might think. The province does charge a small monthly premium (ours is $108/month for a family of four) for the basic coverage. However, most people never even have to write that check: almost all employers pick up the tab for their employees' premiums as part of the standard benefits package; and the province covers it for people on public assistance or disability.
"The basics" covered by this plan include 100% of all doctor's fees, ambulance fares, tests, and everything that happens in a hospital -- in other words, the really big-ticket items that routinely drive American families into bankruptcy. In BC, it doesn't include "extras" like medical equipment, prescriptions, physical therapy or chiropractic care, dental, vision, and so on; and if you want a private or semi-private room with TV and phone, that costs extra (about what you'd pay for a room in a middling hotel). That other stuff does add up; but it's far easier to afford if you're not having to cover the big expenses, too. Furthermore: you can deduct any out-of-pocket health expenses you do have to pay off your income taxes. And, as every American knows by now, drugs aren't nearly as expensive here, either.
Filling the gap between the basics and the extras is the job of the country's remaining private health insurers. Since they're off the hook for the ruinously expensive big-ticket items that can put their own profits at risk, the insurance companies make a tidy business out of offering inexpensive policies that cover all those smaller, more predictable expenses. Top-quality add-on policies typically run in the ballpark of $75 per person in a family per month -- about $300 for a family of four -- if you're stuck buying an individual plan. Group plans are cheap enough that even small employers can afford to offer them as a routine benefit. An average working Canadian with employer-paid basic care and supplemental insurance gets free coverage equal to the best policies now only offered at a few of America's largest corporations. And that employer is probably only paying a couple hundred dollars a month to provide that benefit.
7. Canadian drugs are not the same.
More preposterious bogosity. They are exactly the same drugs, made by the same pharmaceutical companies, often in the same factories. The Canadian drug distribution system, however, has much tighter oversight; and pharmacies and pharmacists are more closely regulated. If there is a difference in Canadian drugs at all, they're actually likely to be safer.
Also: pharmacists here dispense what the doctors tell them to dispense, the first time, without moralizing. I know. It's amazing.
8. Publicly-funded programs will inevitably lead to rationed health care, particularly for the elderly.
False. And bogglingly so. The papers would have a field day if there was the barest hint that this might be true.
One of the things that constantly amazes me here is how well-cared-for the elderly and disabled you see on the streets here are. No, these people are not being thrown out on the curb. In fact, they live longer, healthier, and more productive lives because they're getting a constant level of care that ensures small things get treated before they become big problems.
The health care system also makes it easier on their caregiving adult children, who have more time to look in on Mom and take her on outings because they aren't working 60-hour weeks trying to hold onto a job that gives them insurance.
9. People won't be responsible for their own health if they're not being forced to pay for the consequences.
False. The philosophical basis of America's privatized health care system might best be characterized as medical Calvinism. It's fascinating to watch well-educated secularists who recoil at the Protestant obsession with personal virtue, prosperity as a cardinal sign of election by God, and total responsibility for one's own salvation turn into fire-eyed, moralizing True Believers when it comes to the subject of Taking Responsibility For One's Own Health.
They'll insist that health, like salvation, is entirely in our own hands. If you just have the character and self-discipline to stick to an abstemious regime of careful diet, clean living, and frequent sweat offerings to the Great Treadmill God, you'll never get sick. (Like all good theologies, there's even an unspoken promise of immortality: f you do it really really right, they imply, you might even live forever.) The virtuous Elect can be discerned by their svelte figures and low cholesterol numbers. From here, it's a short leap to the conviction that those who suffer from chronic conditions are victims of their own weaknesses, and simply getting what they deserve. Part of their punishment is being forced to pay for the expensive, heavily marketed pharmaceuticals needed to alleviate these avoidable illnesses. They can't complain. It was their own damned fault; and it's not our responsibility to pay for their sins. In fact, it's recently been suggested that they be shunned, lest they lead the virtuous into sin.
Of course, this is bad theology whether you're applying it to the state of one's soul or one's arteries. The fact is that bad genes, bad luck, and the ravages of age eventually take their toll on all of us -- even the most careful of us. The economics of the Canadian system reflect this very different philosophy: it's built on the belief that maintaining health is not an individual responsibility, but a collective one. Since none of us controls fate, the least we can do is be there for each other as our numbers come up.
This difference is expressed in a few different ways. First: Canadians tend to think of tending to one's health as one of your duties as a citizen. You do what's right because you don't want to take up space in the system, or put that burden on your fellow taxpayers. Second, "taking care of yourself" has a slightly expanded definition here, which includes a greater emphasis on public health. Canadians are serious about not coming to work if you're contagious, and seeing a doctor ASAP if you need to. Staying healthy includes not only diet and exercise; but also taking care to keep your germs to yourself, avoiding stress, and getting things treated while they're still small and cheap to fix.
Third, there's a somewhat larger awareness that stress leads to big-ticket illnesses -- and a somewhat lower cultural tolerance for employers who put people in high-stress situations. Nobody wants to pick up the tab for their greed. And finally, there's a generally greater acceptance on the part of both the elderly and their families that end-of-life heroics may be drawing resources away from people who might put them to better use. You can have them if you want them; but reasonable and compassionate people should be able to take the larger view.
The bottom line: When it comes to getting people to make healthy choices, appealing to their sense of the common good seems to work at least as well as Calvinist moralizing.
10. This all sounds great -- but the taxes to cover it are just unaffordable. And besides, isn't the system in bad financial shape?
False. On one hand, our annual Canadian tax bite runs about 10% higher than our U.S. taxes did. On the other, we're not paying out the equivalent of two new car payments every month to keep the family insured here. When you balance out the difference, we're actually money ahead. When you factor in the greatly increased social stability that follows when everybody's getting their necessary health care, the impact on our quality of life becomes even more signficant.
And True -- but only because this is a universal truth that we need to make our peace with. Yes, the provincial plans are always struggling. So is every single publicly-funded health care system in the world, including the VA and Medicare. There's always tension between what the users of the system want, and what the taxpayers are willing to pay. The balance of power ebbs and flows between them; but no matter where it lies at any given moment, at least one of the pair is always going to be at least somewhat unhappy.
But, as many of us know all too well, there's also constant tension between what patients want and what private insurers are willing to pay. At least when it's in government hands, we can demand some accountability. And my experience in Canada has convinced me that this accountability is what makes all the difference between the two systems.
It is true that Canada's system is not the same as the U.S. system. It's designed to deliver a somewhat different product, to a population that has somewhat different expectations. But the end result is that the vast majority of Canadians get the vast majority of what they need the vast majority of the time. It'll be a good day when when Americans can hold their heads high and proudly make that same declaration.
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