Introduction: Comparing Organized Medicine and Health Policies in France and the United States

A physician, put to sleep in 1900 by a magic spell, awakens in 1930. The countryside and the cities are transformed. Empires have fallen. But medicine has changed little. Like 30 years before, the physician treats weak hearts, calms stubborn coughs, softens expectorations, but he almost never changes the outcome of illnesses which if benign, heal alone, and if serious, almost always kill. A second physician, drowsing off in 1930, is roused from his lethargy in 1960. He recognizes absolutely nothing: acute meningitis, tubercular meningitis, acute tuberculosis, general infections, malignant endocarditis, bronchial pneumonia all can be cured. Addison's disease can be treated, pernicious anemia is no longer pernicious, surgeons open hearts and brains, hemotologists save newborn babies by replacing their blood, psychiatrists become chemists and correct serious disorders of the spirit. Sound waves, lamps, rays and microscopes probe the organs, the tissues, the cells, and even molecules (Bernard, 1966).

Physicians once were harassed practitioners of dubious medicine. Then with great improvements in science and technology and in their own organizing, physicians became prestigious dispensers of health. It was the end of the nineteenth century. Physicians' successes were so impressive that gradually everyone claimed a right to them. Through governments and labor unions, the sick obtained more and more access to health care. However, more access meant more money paid to physicians and their helpers for the goods and services required to operate the industry of health. Subsequently, governments, labor unions, and employers started to question the financial commitment that had grown up around them—and which continued to grow. So physicians came under attack. Some physicians were better than others at resisting attack, at least for a time, and some attacks were more effective than others.

This book seeks to understand why this has been so by focusing on the relations between organized medicine—important providers of health care—and the public and private payers of that health care. The book compares this relationship between physicians and payers in France and the United States. I will concentrate on the contemporary, postwar period, especially the 1970s and 1980s, although the earlier history of medicine's organization and the growth of health is certainly important to the story that I will tell here.

The two countries are suited for comparison because they provide a useful contrast of approximate extreme types along two dimensions: First, France's system quickly evolved into what Roemer (1977) classifies as a public insurance system (cf. Wilsford, 1988; Galant, 1955). The American system, however, has remained more or less resolutely free enterprise in spirit, and largely (though less and less) in fact. These differences are manifested in the distribution of public and private sources of financing health care in the two countries: In 1982, 74.8 percent of the financing of the French health care system was public; 25.2 percent was private. In the United States, only 43 percent of financing was public; 57 percent was private (cf. Heidenheimer et al., 1990:62).

Second, France and the United States exemplify strong versus weak state traditions in the health care sector. The French state tradition of Colbert and Rousseau, in which the state uniquely embodies and protects the general interest, has constituted one important underpinning of state autonomy in health. This contrasts with the American tradition of the "stateless" state wherein the free play of political forces is thought to result in the common good. In the United States, state autonomy in making health policy has been weak as many health interests, especially physicians, have exploited many political openings into the state to their advantage. Yet both France and the United States are advanced industrial democracies which have experienced similar economic expansion and recession in the postwar period.

Equally important, each country also permits free and abundant medical association activity. Physician organizations are numerous and active in the organization of health care delivery systems and in the politics that affect their health care system interests. Moreover, in both countries the medical profession succeeded in using the rise of science and technology at the close of the nineteenth century to establish hegemony over legitimate health care delivery. Most striking, orthodox medicine succeeded in both countries at defining what constituted legitimate.

But the political success of organized medicine in the postwar period has varied. The first argument this book makes is about this difference. In general, French physicians have seen a decline in their political power starting in the 1950s and continuing to the present. American physicians, by contrast, enjoyed almost unvarying (and hard-won) political success until the rise of competition from corporate medicine and the intervention of private employers and insurers in health care decisionmaking from roughly 1975 to the present. Even so, today American physicians continue to be more politically successful than their French counterparts.

Economic pressures on all welfare states have induced states and private insurers to act upon the prerogatives of traditionally favored interest groups such as physicians. The French state, with its "strong" state structures, has been able to shape health care politics more effectively than the "weak" American state. The differences in the distribution of authority and in the tactical advantages available to the French and American states explains what professional associations have chosen to do politically and their effectiveness—and it explains some of the varying success of the two states in controlling health care expenditures. Although officials in both countries consider health care costs a grave problem, there are significant differences in their respective health care expenditures. In 1987, health care expenditures in France totaled 8.6 percent of GDP compared to 11.2 percent of GDP in the United States (CREDES, Eco-Santé, 1989).

We will see subsequently, however, that the lack of strong state responses in the United...