You asked us to compare health insurance coverage in Connecticut with that under Medicare and the national plans in the United Kingdom and France. In particular, you asked us to consider benefit mandates recently enacted or proposed in Connecticut and whether similar benefits are included in the other plans.

SUMMARY

In Connecticut, health insurance benefit mandates for private insurance policies are contained in Chapter 700c of the general statutes. OLR Research Report 2009-R-0317 (copy enclosed) provides a list of existing and recently enacted benefit mandates. Many of the mandates apply to both individual health insurance policies (e. g. , those purchased directly from an insurance company) and group health insurance plans (e. g. , those sponsored by an employer or association). But due to federal law (ERISA), state benefit mandates generally do not apply to self-insured plans. A self-insured health benefit plan is not backed by an insurance policy. Rather, the plan sponsor funds and administers the plan (i. e. , pays claims from its own money, which may include money collected from plan enrollees as premiums).

It appears that benefit mandates proposed and enacted in Connecticut are more condition-specific and offer more incremental coverage than the coverage through Medicare, the United Kingdom's (UK) National Health Service Act, or France's Universal Health Care Act (Couverture Maladie Universelle). In general, these three systems provide medically necessary care to all enrollees. Each is funded by a combination of taxes and, to greater or lesser extents, cost-sharing contributions from individuals and businesses. The major difference is that France and the UK provide health insurance coverage to all residents, regardless of age, income, or health status.

Medicare, one of several government-run health care programs in the United States, is basic health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare uses private health care providers who are paid by the U. S. government through a combination of payroll taxes, premiums, and copayments. It has several parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plan – an alternative to “original” Medicare), and Part D (Medicare prescription drug plan). This report focuses on “original” Medicare (i. e. , Parts A and B).

Medicare Part A helps cover inpatient care in hospitals (critical access hospitals and inpatient rehabilitation facilities), skilled nursing facilities after a hospital stay, religious nonmedical health care institutions, home health care services, and hospice care. Medicare does not cover custodial or long-term care. Medicare Part B helps cover medically-necessary services like doctors' services, outpatient care, and other medical services that Part A does not cover.

France follows a variation of the Bismarck model—named for the Prussian chancellor Otto van Bismarck, inventor of the welfare state in the 19^th century as part of the unification of Germany, according to T. R. Reid, correspondent for The Washington Post, in his recent book The Healing of America (The Penguin Press, New York, 2009). The Bismarck model includes private health insurance plans that (1) cover everybody, (2) provide a standard benefit plan, (3) do not make a profit, and (4) are financed jointly by employers and employees through payroll deductions. Physician practices and hospitals are often private operations but the government regulates medical services and fees to control costs. Employer-sponsored insurance in the United States follows the Bismarck model, except that most U. S. health care providers and insurers work for profit.

Today, France provides permanent and qualified residents statutory, nonprofit health insurance plans—the caisses d'assurance maladie, or sickness insurance funds—with cost sharing requirements. Nonprofit cooperatives and private insurers exist to provide supplemental coverage and optional benefits. French residents do not have a choice of plans under the Universal Health Care Act, enacted in 2000. Rather, the insurance fund a person comes under depends on his or her line of work or geographic region and he or she keeps it for life, according to Reid. There are three basic funds: one each for (1) farm workers, (2) salaried workers, and (3) independent professionals and the self-employed. The employer and the employee share the premium cost, which is taken through payroll deductions. When a person loses his or her job, the government pays the portion of premiums that the employer previously paid. The government also pays the premium for anyone who is unemployed.

In comparison, Reid notes that the UK follows the Beveridge model—a universal health care single-payor model inspired by social reformer William Beveridge, who designed the British National Health Service system adopted through the National Health Service Act of 1946 (NHS). The health insurance provided to veterans and the military in the United States follows the Beveridge model.

Under UK's universal single-payor model, health care is provided through the government, generally requires no cost sharing at the time of service, and is financed solely through a series of taxes (e. g. , sales, income, and social security taxes). There are generally no bills given to patients; the government pays all out of the taxes collected. As part of the NHS, an independent organization—the National Institute for Health and Clinical Excellence (NICE)—is responsible for promoting good health and preventing and treating illness. One of the ways it does this is by developing evidence-based clinical guidelines that health professionals must follow.

CONNECTICUT

In 2009, the legislature passed four bills that mandate certain health insurance coverage, one of which the governor vetoed. The three surviving acts are effective January 1, 2010 and are shown in Table 1.

Table 1: Health Insurance Mandates Enacted in 2009

The legislature also passed PA 09-188, but the governor vetoed the act. PA 09-188 was a combination of several proposed bills. It required insurance coverage for certain bone marrow testing, colonoscopies, hearing aids, ostomy supplies and appliances, prosthetic devices, and wigs. It also required group health insurers to offer health wellness programs that provide insured people participation incentives.

Table 2 shows bills proposed in 2009 to mandate certain insurance coverage but not enacted. Table 3 shows those proposed but not enacted in 2008. Table 4 shows those proposed but not enacted in 2007.

Table 2: Health Insurance Mandates — 2009 Proposed but Not Enacted

Table 3: Health Insurance Mandates — 2008 Proposed but Not Enacted

Table 4: Health Insurance Mandates — 2007 Proposed but Not Enacted

MEDICARE

Table 5 shows many of the services Medicare covers. Coverage may be subject to certain conditions and limitations, including patient copayments and coinsurance. For more information regarding these conditions and limitations, refer to the enclosed federal government publication regarding Medicare, which may be viewed online at: http: //www. medicare. gov/Publications/Pubs/pdf/10116. pdf.

Table 5: What “Original” Medicare Covers

No Medicare Payment for Identified “Never Events”

The federal Deficit Reduction Act of 2005 required the federal Medicare agency, beginning October 1, 2008, to limit payments to hospitals for preventable medical errors that result in serious consequences for patients. Since then, the agency has identified selected costly or common conditions that it considers to be reasonably preventable by following evidence-based guidelines. Medicare will not pay a hospital for any increased costs it incurs as a result of one of these events occurring (i. e. , treating a condition that was not present when the patient was admitted to the hospital). Medicare continues to pay for the physician and other covered items or services needed to treat the hospital-acquired condition. The following conditions have been identified:

1. object inadvertently left in after surgery;

2. air embolism;

3. blood incompatibility;

4. catheter-associated urinary tract infection;

5. pressure ulcer;

6. vascular catheter-associated infection;

7. surgical site infection (chest infection) after coronary artery bypass graft surgery;

8. certain types of falls and traumas;

9. surgical site infections following certain elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity;

10. certain manifestations of poor control of blood sugar levels; and

11. deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures.

“Never Events” in Connecticut

PA 09-206, An Act Concerning Health Care Cost Control Initiatives, prohibits hospitals and outpatient surgical facilities in Connecticut, beginning January 1, 2010, from seeking payment for costs associated with a hospital-acquired condition Medicare identifies as not payable. This applies regardless of the patient's insurance status or sources of payment (including self-pay), except as the law may otherwise provide.

UNITED KINGDOM

The National Health Service Act of 1946 set the framework for the health services finance and delivery system of the United Kingdom (UK). The National Health Service (NHS) began operating in 1948 under the principle that the state had the collective responsibility to provide equal access to a comprehensive health system free at the point of service.

Unless otherwise noted, the information that follows is from Health Care Systems Around the World by Alyssa Kim Schabloski (Insure the Uninsured Project, 2008, pp 31-34; available at http: //www. itup. org/Reports/Fresh%20Thinking/Health_Care_Systems_Around_World. pdf).

Policy and Management

The Department of Health oversees health policy in the UK and various trusts are responsible for coordinating the delivery of health care.

Department of Health. The responsibility for health and personal social services of each of the constituent countries of the UK lies with the Department of Health, which oversees local planning, regulation, inspection, and policy development. The secretary of state for health answers directly to the UK parliament. The central government sets health priorities for NHS as a whole and controls the overall pool of funds; NHS authorities, in turn, provide planning guidance to the health authorities in terms of service and financial networks. The ten strategic health authorities manage health care and disburse funds on a regional basis, linking the Department with the NHS.

NHS Trusts. The NHS is divided into primary and secondary care services. Primary care services are delivered by “primary care trusts. ” These primary care trusts contract with local general practitioners, surgeons, dentists, and opticians to delivery primary care. The primary care trusts receive about 75% of the overall NHS budget.

Secondary care refers generally to either emergency or elective care (e. g. , hospitals, emergency transportation, social care). “Acute trusts” (one type of secondary trust) manage the delivery of care in hospitals to ensure that hospitals deliver care efficiently. The 209 NHS hospital trusts oversee 1600 NHS hospitals and specialty care centers.

Figure 1 and Table 6 depict NHS' structure and features.

Figure 1: Structure of NHS Authorities and Trusts

Table 6: Features of NHS Trusts and Authorities

National Institute for Health and Clinical Excellence (NICE)

The National Institute for Health and Clinical Excellence (NICE) is an independent organization responsible for (1) determining which medical protocols must be followed and (2) providing national advice on promoting good health and preventing and treating illness. NICE was established in 1999 to offer NHS healthcare professionals advice on how to provide their patients with the highest attainable standards of care. In 2005, its charge was expanded to include health promotion and disease prevention.

Cost Effective, Evidence-Based Care. NICE has its origins in the creation of Health Technology Assessment Centers in British universities in the early 1990s, according to Sir Michael Rawlins, NICE Chairman, in an interview with Nicholas Timmins for Health Affairs (Vol. 28, No. 5, Sept/Oct 2009, pp 1360-65). The centers were responsible for advances in evidence-based medicine. NICE was created to assess the cost effectiveness of the treatment protocols suggested by the centers. Thus, NICE is charged with implementing cost effective, evidence-based medicine throughout the UK. By law, the primary care trusts must implement NICE's recommendations for cost effective treatment. The benefits and services NHS covers are whatever services NICE has approved for the indicated condition and person's status (e. g. , condition, age).

Public Health Guidelines. NICE has four programs that produce public health guidance (see Table 7 below). These include developing clinical guidelines and recommendations on health technology (e. g. , surgical interventions and pharmaceuticals) and public health. Much of NICE's guidance takes into account clinical effectiveness and cost effectiveness. Some guidance just looks at efficacy.

“Clinical effectiveness” refers to the extent to which a specific treatment or intervention, when used under usual or everyday conditions, has a beneficial effect on the course or outcome of disease compared to no treatment or other routine care. “Cost effectiveness” means value for money (e. g. , a health care treatment is said to be cost effective if it gives a greater health gain than could be achieved by using the resources in other ways). “Efficacy” is the extent to which a specific treatment or intervention, under ideally controlled conditions, has a beneficial effect on the course or outcome of disease compared with no treatment or other routine care.

When developing guidance, NICE bases its decisions on the best available evidence, but it may not always be of good quality or complete. Those developing NICE's guidance, therefore, are required to make (1) scientific value judgments (i. e. , interpreting the quality and significance of the evidence available) and (2) social value judgments (i. e. , relating to society rather than science).

NICE's guidelines are purely recommendations to the provider community. The primary care trusts are not required to implement them. NICE has created about 90 guidelines to date and has another 40 in development, according to Rawlins.

Table 7: NICE Guidance Programs

Source: http: //www. nice. org. uk/media/C18/30/SVJ2PUBLICATION2008. pdf

Payors

Health care in the UK is mostly purchased through the primary care trusts and private insurers. There are about 150 primary care trusts that oversee 29,000 general practitioners and 18,000 dentists. The trusts are responsible for assessing the area's health care needs and contracting, within a fixed budget, for the appropriate level of services to meet those needs.

There are 175 acute trusts and 60 mental health trusts that oversee 1,600 NHS hospitals and specialist care centers. Foundation trusts are a new type of NHS hospital, of which there are 115 available across England.

Emergency vehicles are provided in England by 11 ambulance services trusts. The Scottish, Welsh, and Northern Ireland ambulance services provide cover for those countries. NHS care trusts provide care in both health and social fields. There are a few care trusts, which are based mainly in England. NHS mental health services trusts provide mental health care in England and are overseen by the primary care trusts.

Private health insurance is available in two main ways: employment-based group insurance and individual insurance. In 1996, about 10% of the population had private insurance. Of those, more than half—about 59%—were insured through an employer-based plan; 31% purchases individual insurance; and 10% purchased insurance through an “umbrella organization” (e. g. , an association whose members may voluntarily purchase coverage).

Providers

The NHS is the largest employer in Europe with more than one million full-time employees and 2,000 hospitals, according to Reid.

Hospitals. District general hospitals are the foundation of hospital care in the UK. These hospitals are widely disbursed throughout NHS. Tertiary care facilities (i. e. , highly specialized hospitals) operate on more regional levels. Patients enter tertiary care facilities after being referred from the district hospitals. Community hospitals often provide long-term care, particularly for the elderly. There are also more than 300 private hospitals operating in the UK.

Doctors. General practitioners make up about 60% of all doctors in the UK, compared with about 35% in the United States. In the UK, general practitioners are private professionals who contract with and receive payment from the NHS. Contract negotiations occur between doctors' representatives and the government. Doctors are paid using a capitation method, meaning each doctor receives a set fee per patient who is registered with that doctor.

General practitioners serve as gatekeepers to “consultants” (i. e. , specialists). In order to see a specialist, a patient must first see their general practitioner. More than 99% of the population has a registered general practitioner, and about 90% of all patient contact is with a general practitioner.

The U. K. is experimenting with a new payment system called the Index of Quality Indicators, according to Reid. Under this system, a doctor earns more for successful results (i. e. , keeping patients healthy). This pay for performance system is intended to replace the capitation method, which pays the doctor whether or not the patient gets better. The U. K. 's pay for performance system would grade doctors on about five dozen “quality indicators” meant to measure a doctor's performance.

According to Reid, there continues to be disagreement on what indicators should be used. As a result, the British Medical Association instead has established “best practices” for treating various diseases. NHS pays doctors a bonus for complying with the best practices, up to about $ 125,000 a year. The bonus payments are in addition to the base capitation rate, which earns a doctor with an average patient load of 2,000 registered patients about $ 62,500 a year.

A general practitioner's medial malpractice insurance costs about $ 4,200 a year. According to Reid, this is about how much a general practitioner in the United States pays for one month of coverage. And in the U. K. , any doctor who can prove that he or she followed guidelines approved by NICE is immune from malpractice liability. Additionally, medical school tuition is low (about $ 4,000 a year) and local governments often pay the tuition for medical students from their community.

Eligibility and Access

All UK residents are eligible for care through the NHS. Services are provided free of charge at the point of care unless a charge is expressly authorized under a more recent law, namely, the Health Service Act of 1977. A copay of about $ 10 is imposed on each prescription drug, but the copay is waived for children, people over age 60, pregnant women, and the chronically ill. Thus, about 85% of the British receive their medications at no charge, according to Reid.

Patients must choose a general practitioner within their geographical region. The general practitioner serves as a gatekeeper, thus, patients must go through their general practitioner to have access to specialist care, except in the case of an emergency.

The NHS allows patients to upgrade their services without acquiring private insurance. Patients may receive an “amenity room” (i. e. , a private room) through the NHS for an additional fee. For privately insured patients who need care, NHS trusts also may offer these private rooms at NHS facilities.

One way the NHS keeps its system cost efficient is by removing administrative bureaucracy (other than gatekeepers and NICE's approved treatments). For example, there are no doctor bills, thus no insurance billing offices and no doctor's staff to handle claims and billing.

Benefits and Social Welfare

Although treatment through the NHS is free at the point of delivery, there may still be some costs (e. g. , an ambulance to hospital). However, much or all of the cost can be reimbursed by the NHS. Residents login to a website, NHS Choices (http: //www. nhs. uk/Pages/HomePage. aspx), to find full details of how to claim reimbursement of money spent on treatment for dental work, vision services, wigs, fabric supports, and travel costs, and prescription drugs. They can access a full list of eligibility for reimbursement.

Although the local governments have primary responsibility for social services, the NHS also contributes to the provision of these services. The UK also provides social care for the elderly and those with mental illness or learning disabilities. Care ranges from long-term residential or nursing home care to home health care. The local government and social services departments share responsibility with NHS for these services.

Financing

With a budget of more than £90 billion (about $ 146. 5 billion), the NHS is the largest publicly funded health system in the world. Financing for the NHS comes primarily from general tax revenues. In 2006, 87% of health spending was financed by public funds—nearly 80% of the total budget is disbursed to the primary care trusts.

The Consolidated Fund of general tax revenues provided 81. 5% of NHS financing in 1997. National Insurance contributions comprised another 12. 2%. Patient charges accounted for 2. 1%, and the remaining 4. 2% came from repayments of NHS trust interest-bearing debt (3. 0%) and other sources (1. 2%). That year, private funds accounted for 14. 6% of total health expenditures.

Sales tax runs between 15% and 17. 5% and income and social security taxes are higher than in the United States at every income bracket, according to Reid.

FRANCE

France has had a national insurance system since 1945. With the passage of the Universal Health Care Act (Couverture Maladie Universelle), it has had a universal statutory insurance system (coverage for all) since 2000. A private insurance market exists to provide supplementary coverage and optional benefits (e. g. , private hospital room). Most people purchase some amount of supplementary coverage.

Unless otherwise noted, the information that follows is from Health Care Systems Around the World by Alyssa Kim Schabloski (Insure the Uninsured Project, 2008, pp 8-11; available at http: //www. itup. org/Reports/Fresh%20Thinking/Health_Care_Systems_Around_World. pdf).

Policy and Management

In France, responsibility for health services is split between the national, regional, and departmental levels of government. At the national level, parliament annually sets the ceiling for health insurance expenditures and may adopt new benefit provisions. The Ministry of Health, which regulates much of the health care system:

1. allocates national funds among the sectors and regions;

2. sets prices;

3. approves negotiated provider fee schedules;

4. establishes hospital safety standards;

5. sets the number of students to be admitted to medical school each year; and

6. defines national health priorities.

At the regional level, regional hospital agencies are responsible for allocating funds to public hospitals, adjusting taxes for private for-profit hospitals, and planning for all hospitals. These agencies report to the Minister of Health. At the department level, general councils provide social, health, and public health services.

Payors

French residents do not have a choice of plans under the Universal Health Care Act, enacted in 2000. Rather, the insurance fund a person comes under depends on his or her line of work or geographic region and he or she keeps it for life, according to Reid. There are three basic funds under the umbrella of the national union health insurance fund (union nationale des caisses d'assurance maladies—UNCAM):

The employer and the employee share the premium cost, which is taken through payroll deductions. When a person loses his or her job, the government pays the portion of premiums that the employer previously paid. The government also pays the premium for anyone who is unemployed.

Each national health insurance fund distributes money to regional and local funds. The funds contract for services with self-employed providers and negotiate the level of charges. CNAMTS covers approximately 85. 6% of the population. Members include both employees in commerce and industry and their families. MSA covers farmers and agricultural employees, approximately 7. 2% of the population. CANAM covers non-agricultural self-employed people, about 5% of the population.

Under the statutory health insurance plan, the reimbursement of health care costs accounts for 84. 9% of total expenditures. The remaining 15. 1% is paid out as cash allowances for maternity, illness, work-related injuries, or disability. Reimbursements are made either to the patient, who paid out-of-pocket, or to the provider. Increasingly, pharmacy and laboratory benefits are being paid directly by the insurers.

To cover the cost of coverage that is not reimbursed under the statutory health insurance scheme, 86% of the population purchased supplemental private health insurance in 2000. However, only 43% purchase this directly from insurers, as employers purchase most coverage through a group contract.

Providers

The French health care system includes both public and private health care providers.

Hospitals. Of the more than 4,000 hospitals operating in France, one fourth (about 1,000) are public hospitals and a third (about 1,400) are non-profit private hospitals. Private, for-profit hospitals make up the remaining majority with more than 1,600, but they tend to specialize in particular medical, surgical, or obstetric procedures.

Although all hospitals receive a per diem payment from the insurance fund, the services the fee covers varies based on the type of hospital. Public hospitals receive a single per diem rate that covers all services provided, while private for-profit hospitals receive payments for some services separately on a fee-for-service basis. Patients also contribute a small amount (about €10. 67 or about U. S. $ 15. 50) per day of hospital stay.

In 2009, France is changing how state-run hospitals are paid. Instead of receiving an annual lump sum, hospitals will now have to (1) maintain a balanced budget, (2) have business managers, and (3) charge on a fee-for-service basis, which the Ministry of Health predicts will allow for better expense tracking.

Doctors. In 2000, there were about 194,000 physicians in France; 51% specialists and 49% primary care doctors (i. e. , general practitioners). Half of the specialists and about a third of the general practitioners are salaried. For doctors associated with a government-run hospital, salaries are, on average, about $ 52,000 a year for a general practitioner and $ 65,000 for a specialist. As a result, an average office visit with a general practitioner is about $ 27 and about $ 34 for a consultation with a specialist, according to Reid.

Doctors in France do not pay for medical school. The national government bears the cost. And, according to Reid, a French doctor's annual medical malpractice insurance premium is less than what a doctor in the United States pays for a week's worth of coverage: about $ 170 a year for a general practitioner and about $ 650 for an orthopedic surgeon.

Doctors can prescribe treatment without needing approval from the government. They post detailed lists of charges in their waiting rooms and patients pay for services at the time they receive treatment. Providers negotiate a fee reimbursement schedule with the national insurance funds to determine the rate of each procedure. The funds pay the doctor within days of rendering care to a patient.

Eligibility and Access

Although France provided nearly all of its residents with health insurance prior to 2000, the Universal Health Care Act expanded coverage to all French residents. Those who are eligible for full coverage through the statutory insurance funds are (1) permanent residents (i. e. , those with a regular residence permit) and (2) qualified illegal residents (those who (a) can justify more then three months presence in France and (b) do not have sufficient financial resources).

Residents may consume as much health care as they like, but are responsible for sharing the cost. Most patients pay the full cost of services out-of-pocket and request reimbursement from the statutory fund, with the exception of those requiring hospitalization and low-income beneficiaries. Single residents whose annual taxable income falls below a certain amount per year (€8774 for 2008-09, about U. S. $ 12,776) are entitled to free coverage. Also, no one is expected to pay more than about $ 100 in a single day, regardless of the services received.

Patients may choose to see any licensed practitioner at any time without limit. The French average 4. 7 contacts with a general practitioner (not necessarily the same one) each year.

Carte Vitale

An encrypted carte vitale (“vital card” or “card of life”) digitally holds a person's medical records from 1998 to the present, according to Reid. Digital and electronic records are used throughout France, eliminating paper records and the need for physical storage space. Each person age 15 and older carriers a carte vitale and a younger child's information is contained on his or her mother's card.

The card contains a record of each diagnosis and treatment a person has received. It also holds the billing records for a person's interactions with the medical system, including how much the (1) doctor billed, (2) patient paid, and (3) insurance fund should pay to the doctor and reimburse to the patient. When a doctor updates a patient's card for the current visit, he or she presses the “transmit” key, which automatically bills the insurance fund. The fund pays the doctor within five days and the patient within a month. It is illegal for the funds to deny a transmitted claim. Doctors' offices tend not to need administrative staff to interact with the insurance funds since the billing and payment is automatic through using the carte vitale.

Health Insurance Benefits and Social Welfare

In France, the statutory insurance funds provide coverage for:

1. inpatient hospital services, including rehabilitation;

2. outpatient care (from general practitioners, specialists, dentists, and midwives);

3. diagnostic services and care;

4. eligible pharmaceutical drugs and devices;

5. health care-related transportation (e. g. , ambulance); and

6. preventive care.

France's local authorities have primary responsibility to provide services for other health-related services, including services to those with mental illness and addictions as well as for the elderly and disabled.

Typically, patients receive only partial reimbursement; thus, they pay the equivalent of a copayment for services. Patients without supplemental insurance typically receive a reimbursement rate of 70% for physician and dentist services and 60% for auxiliary and laboratory services.

There are payment exemptions for patients with a certain chronic or debilitating health status, those receiving a certain type of care, or due to the status of the patient (such as pregnant women or those injured in the workplace). Thus, certain people get 100% coverage, even for conditions not directly related to the primary illness, due to their medical or other status.

Financing

There are two main sources of revenue for the statutory insurance funds: (1) employee and employer contributions and (2) taxes, as shown in Table 8.

Employers contribute more than 50% of the cost of the insurance funds. Employees' earnings-based contributions are levied at 0. 75% of gross earnings. Each resident pays a general social tax based on total income. The health insurance tax rate for earned income, capital gains, and gambling winnings is 5. 25%, while benefits such as pensions or social allowances are taxed at a rate of 3. 95%. The remaining funds are provided through state subsidies and specifically earmarked taxes, such as car usage and alcohol and tobacco consumption. Pharmaceutical companies also contribute through a tax on advertising.

Table 8: Revenue Sources for France's Statutory Insurance Funds (2000)

According to Reid, the French health care system “offers a maximum of free choice among skillful doctors and well-equipped hospitals, with little or no waiting, at bargain-basement prices” (p. 63). As a result, because patients are unwilling to pay more, the three insurance funds operate at a deficit, costs are increasing significantly, and the Ministry of Health continues to reform the system every few years to find cost savings. So far, the system's saving grace has been its efficiencies, as demonstrated by the carte vitale, which has kept administrative expenses very low.

HOW THE UNITED STATES COMPARES TO OTHER COUNTRIES

The below information is from Reid's “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care” (The Penguin Press, 2009). Reid, a veteran foreign correspondent, compiled statistics to show how the United States compares to other countries relative to health care. The following tables include various countries' rankings for:

● Health Expenditure as a Percentage of Gross Domestic Product Table 9),

● Infant Mortality (Table 10),

● Top Countries for Healthy Living (Table 11),

● Top Countries for Overall Health Care System Performance (Table 12),

● Top Countries for Avoidable Mortality (Table 13), and

● Percentage of Health Care Patients Pay Out-of-Pocket (Table 14).

Table 9: Health Expenditure as a Percentage of Gross Domestic Product (2005)

Table 10: Infant Mortality (2005)

Source: Organisation for Economic Cooperation and Development (OECD),** Health at a Glance, 2007

**The OECD is made up of 30 member countries, including the United States, committed to democratic government and the market economy. According to its 2009 annual statement, it provides a forum where governments can compare and exchange policy experiences, identify good practices and promote decisions and recommendations. GDP, a measure of a country's economic performance, is the market value of all final goods and services made within the borders of a nation in a year.

Table 11: Top Countries for Healthy Living** (2000)

Table 12: Top Countries for Overall Health Care System Performance (2000)

Source: World Health Organization, World Health Report, 2000

**Based on 191 member countries' “healthy life expectancies. ” This reflects how long a healthy baby born in 2000 can expect to live in full health. This measurement is approximately seven years shorter than the more straight forward “life expectancy at birth” measurement. It takes into consideration a nation's health habits, access to medical care, both disease prevention and treatment.

Table 13: Top Countries for Avoidable Mortality** (2006)

Table 14: Percentage of Health Care Patients Pay Out-of-Pocket (2001)

Source: WHO, World Health Report, 2003

**Based on the number of people in each of 19 countries studied who contracted a potentially fatal but treatable medical condition, were treated successfully, and survived.

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