As the Patient Protection and Affordable Care Act takes shape,it is often compared to European health care and, in particular, tothe system in France. It's an easy comparison to make: Both arebuilt on a large, highly regulated private sector and rely mainlyon third-party, employment-based insurers.

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In the United States and France, workers and employers split thecost of health insurance. Both countries cringe at the thought ofwaiting lists for elective surgeries or to see a specialist, andboth fear any system that would force them to give up their choicein medical providers.

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But there is a great distinction to be made between theambitions of the two countries, and the French will let you knowit. Their health coverage is universal, extending across age groupsand income levels. TheU.S.system provides government-sponsoredcoverage only to certain segments of the population, both beforeand after the enactment of the new federal health care law in whichprivate insurance is subsidized for some low and middle-incomeAmericans.

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It was a point made last year by French Minister of Health andSocial Affairs Marisol Touraine. Many French find it surprisingthat Americans would resist a system of near-universal healthcoverage, she told reporters outside the Elysee Palace.

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There is, however, a comparison the French will like even less:the suggestion that their system is anything like Canadian- orBritish-style socialized medicine.

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“The idea of direct access to specialists, the doctor-patientrelationship, and access to small private practices is veryappealing in France, and they would never put up with a U.K.-stylenational health service. They consider it outrageous,” said PaulDutton, a historian at NorthernArizonaUniversityand author ofDifferential Diagnoses: A Comparative History of Health CareProblems and Solutions in the United States and France. “Thatis as far removed from France as it is from the United States.Still, there are the same issues that they face: how to sharenetworks, how to keep costs down. Most countries, really, arestruggling with that.”

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The French way

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France's health care system is a public-private mix ofgovernment and marketplace. Its national insurance program paysabout 70 percent of the bill, funded mostly by payroll and incometaxes. The remaining amount is covered by private insurance, whichnearly every person has.

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The government regulates hospital fees and drug costs andnegotiates with medical unions that set doctors' fees. SécuritéSociale, a standardized billing and patient reimbursement system,stands in for the army of billing administrators typically seen inAmerican doctors' offices. This makes insurance battles far lesscommon.

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“They don't have huge battles between back offices of doctorsand insurers, back and forth, arguing over rates and money,” Duttonpoints out. “Many middlemen are eliminated. It is much moreefficient and cheaper.”

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The doctors also are cheaper. The average French physician makesabout twice as much as the average earnings of his or hercompatriots, compared with the average American generalpractitioner who earns more than five times theaverageU.S.wage.

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In fact, U.S. doctors were estimated to earn double the medianfor 21 nations in the most recent data provided by the Paris-basedOrganization for Economic Cooperation and Development. Thedifference was nearly threefold for specialists.

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That is a direct reflection of higher costs for services. Aroutine visit to a French doctor will cost $23 in France, while hisor her American counterpart will charge nearly four times asmuch.

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In 2010, the total capital expenditure per person was $8,233 inthe United States, more than double the expenditure in France($3,974) and the OECD average of $3,265.

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Less than half of health spending in the United States waspublicly financed at the time, compared with an average of 72percent among other countries ranked by the OECD. Yetgovernment spending on health care was greater than nearly all ofthe other countries, with the exception o f Norway and theNetherlands.

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Tough comparison

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Efforts to measure or rank quality, especially compared withspending, have been met with unease. The most recent attempt, bythe World Health Organization nearly a decade ago, graded eachnation's system on lifespan, responsiveness, health care outcomesand individual spending; it ranked France No. 1 and the UnitedStates No. 37.

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Many researchers have been skeptical of the report, pointing outthat factors such as dietary habits are beyond the control of acountry's health care system.

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The OECD did make some comparisons in its health data reportreleased last year.Franceranked above the average of 34 countriesin terms of the number of physicians and life expectancy at birth,partly attributed to progress in medical care.

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TheUnited Stateswas found to have fewer physicians available forthe population compared with the average, but it was ranked high interms of access to technology such as MRIs. TheUnited Statesalsohad the highest breast cancer five-year survival rate.

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There is one aspect ofFrance's system that has been especiallylauded: The sicker a French citizen is, the better they are takencare of by the nation's system. For people with any of 30 long-termand expensive illnesses, the government pays entirely forsurgeries, therapies and drugs. It is somewhat in the same vein asthe Affordable Care Act prohibiting health plans from limiting ordenying coverage or charging more based on a person's medicalhistory.

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There are also a number of challenges. Both the WHO and the OECDhighlighted pressures they face to bring spending under control asan aging population threatens to stress both systems.

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The cost factor

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Like the United States, France is looking at new ways to ensurepeople have access to care and to reduce health inequalities, saidIsabelle Durand-Zaleski, director of Paris-based health economicsand health services research unit Urc Eco.

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“Every French citizen is entitled to health coverage, and thatis an important achievement,” said Durand-Zaleski, who is also thechief of public health for hospital group Henri Mondor-AlbertChenevier.

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“Still, we are seeing supplemental benefits, which cover extrabilling for dental care or eye care, being reduced somewhat.Especially on the economic downturn, insurers tend to try andreduce the benefits, but there is currently a lot of lobbying andpressure at the Parliament to target that.”

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While about 95 percent ofFrance's population has supplementalinsurance in addition to the public-funded baseline insurance,mostly provided by employers, some loopholes exist. Some employersrecruit staff on casual or short-term contracts to avoid payingbenefits. But this affects a very small percentage, Durand-Zaleskisaid, and supplemental insurance is still affordable. Plans can bepurchased for as little as €20 a month.

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Premiums in theUnited Stateshave soared since the 2010 enactmentof the Affordable Care Act. A survey by the Kaiser FamilyFoundation found that premiums for single coverage in theUnitedStateslast year averaged $5,615, or $468 a month. Over five years,the costs have increased 25 percent for individual coverage and 30percent for family coverage.

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That isn't to say that the French are not, in one way oranother, paying a high price for the services they receive. Theypay 21 percent of their income tax toward health care.

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Look to the Swiss

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Perhaps the United Statesshould aspire to be more likeFrance'sneighbor to the north. Switzerland already has what PPACA hopes toachieve: universal coverage through mandatory private insurance.The Swiss are required to purchase a plan from one of 92 insurersfor an average premium of about $300 a month. The governmentregulates drug prices and fees for medical tests; patients canchoose their doctor; and there are no waits for specialists.Insurers are not allowed to deny or delay coverage due for reasonsother than fraud.

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The benefits include the freedom to choose insurance without thebacking of an employer, giving people the freedom to leave a jobwithout worrying about whether doing so would jeopardize theirhealth or well-being. More than 99 percent of the population isinsured, and those who come into the country without buyinginsurance eventually receive a bill from the government, which hasgone ahead and picked one for them.

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Are they happy with it? A 2011 Deloitte survey found that morethan half of Swiss respondents gave their health care system agrade of A or B, as did half of the French who were polled. Exactlyhalf—50 percent—of Canadians gave the high grade, as did 46 percentof Britons.

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Only 22 percent of Americans did the same.

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