Adjusting to life in a new country can be difficult. Along with new cultural customs, food, and language, there’s a new health care system to get used to.
In this episode of The Dose, Shanoor Seervai speaks with Natacha Lemaire of the French Ministry of Health. Natacha spent a year in the U.S. on a fellowship, and experienced multiple moments of surprise and frustration as she learned to navigate the U.S. health system to care for herself and her family.
Coming from France, where everyone has coverage, Natacha was struck by the high costs of care in the U.S., the lack of transparency around prices, and the frequency with which medical tests were ordered for her and her family.
SHANOOR SEERVAI: Taking care of kids with allergies can be stressful. Especially when you can’t control what they’re eating—like school lunch. One family who moved to the U.S. from France last year with 12-year-old twin boys knows this anxiety all too well. Their story meets head-on with another common health care anxiety: costs. Natacha, the mom, is going to tell us their story.
NATACHA LEMAIRE: One of the boys had an allergy because of the food, so he took his medication, but it was quite anxious and had some problems to breathe. So he went to the nurse, the school nurse. So the nurse did use the EpiPen that he had the first time. We never used it, never, never, and then she called 911.
And so the ambulance came, took the kid.
SHANOOR SEERVAI: Next, Natacha’s son was on his way to the hospital. Here she is again.
NATACHA LEMAIRE: Then because of the EpiPen and all the medicine, they had to keep him for a couple of hours to monitor him and make sure that everything was fine. So by the end of the day he came back home. Then we received the bill for the ambulance and because my husband gave the information, but something — I don't know, they didn't take into account at the beginning, so we received the bill for the uninsured rate and it was $3,500 for like a 10-minute ride because it was very close.
SHANOOR SEERVAI: Thirty-five hundred dollars? That’s so expensive. What did you do?
NATACHA LEMAIRE: So we called the company, gave the information, and received a second invoice, second bill, with the insured rate and that was $867. And this is when we understood that when you are uninsured, you pay like four or five times more than people who are insured, which is something very, very strange for us.
Well, compared to the way that we deal with this kind of issue in my country, we thought that the kid has been overmedicated. All of it was not necessary. I'm not sure the EpiPen was necessary and two intravenous cortisone shots seems a lot.
We came to the U.S. with — I think we had four of them, two for each kid, just in case, and also, you know, in France we paid just the deductible for the EpiPens, so 50 cents each.
Compared to your $400 or $500 apiece in the States.
SHANOOR SEERVAI: That’s right. EpiPens cost fifty cents in France. Welcome back to The Dose, conversations about health care in developed countries where everyone has coverage, and how their health systems are different from our system in the United States. You just heard that from Natacha Lemaire. She's an expert in health policy and has worked for several years for the French Ministry of Health. Natacha came to the United States in 2016 to study our policies around coordination of care. While she lived in the States, she was able to compare our health care system to what she has at home. She’s going to tell us about what shocked her as she tried to take care of her health and her family.
Natacha, thanks for joining us.
NATACHA LEMAIRE: My pleasure.
First Impressions of the U.S. Health System
SHANOOR SEERVAI: All right. So, to get started, would you like to tell me a little bit about what was most surprising to you about the health care system in America when you first arrived?
NATACHA LEMAIRE: I think that the biggest surprise for me was that the prices were not public and that I couldn't know beforehand, before using the service, how much it would cost to me and to the insurance. And for me it was just not possible to understand that as in my country it's all public.
SHANOOR SEERVAI: What do you mean by that — is it that everyone knows, up front, exactly what a service will cost?
NATACHA LEMAIRE: First of all, you have a price that is defined by our National Health Insurance and this — the price is the same for the service all over France, wherever you go.
SHANOOR SEERVAI: The National Health Insurance in France consists of three main nonprofit insurance funds that are financed and supervised by the government. The funds negotiate costs with health care providers, and that keeps things cheaper than they are in the U.S.
In the U.S., each insurance company or payer like Medicare conducts its own negotiations with hospitals and doctors to set the price for every single medical service. That’s why there’s so much variation from one hospital to the next.
In France, on the other hand, the price for an MRI costs the same at a local health provider in a small village as it does in the best hospital in Paris.
If you need to go see your primary care doctor, you pay 25 euros.
NATACHA LEMAIRE: Exactly. And for specialists you can pay either 25 euros or if they depend on the second tier, like — let's call it this way — you may have to pay more, but then the price is displayed in the waiting room of the physician.
And when it is more than 100 euros it's considered to be very expensive.
SHANOOR SEERVAI: When you walk into a doctor's office, it's like there's a menu on the wall.
And so you can see right before you get anything what your out-of-pocket cost would be. And then maybe you decide that you can't afford that right now, and then you just don't get the service. And even though your insurance will reimburse you for most, if not all, of that cost, the French think it’s important to pay something at the point of service. That’s because they believe having health care is important, and the act of paying even a small amount for it on the spot makes people value it.
NATACHA LEMAIRE: Exactly. If you go to the hospital, as you have, we have a deductible per day for the inpatient stay, and the rate is — the current rate is 18 euros and it will be 20 from next year per day.
SHANOOR SEERVAI: Twenty euros per day to stay in the hospital.
NATACHA LEMAIRE: Yeah, out-of-pocket money.
SHANOOR SEERVAI: Wow, 20 euros per day out-of-pocket. That's less than $25.
NATACHA LEMAIRE: Yes.
SHANOOR SEERVAI: That's like eating lunch in Manhattan.
NATACHA LEMAIRE: You said it.
Surprise Medical Bills
SHANOOR SEERVAI: Of course, people are paying for their health care in another way in France – through taxes that employers and employees pay. The French health care system is actually quite expensive compared to other countries, about 12 percent of the GDP. But it still costs less than in the U.S., where health care spending is 18 percent, nearly one-fifth of the GDP. Okay, back to Natacha.
When you came to the U.S., how did you figure out what something was going to cost you?
NATACHA LEMAIRE: Well, I tried to understand and have the information beforehand, but in one case I couldn't because it was a kind of emergency, so I had no time to do anything and I had just to have the service, the procedure.
SHANOOR SEERVAI: Okay. What was the emergency? Tell me what happened.
NATACHA LEMAIRE: It was a ski injury. Someone, a snowboarder just ran over me. So I had —
SHANOOR SEERVAI: Oh, wow.
NATACHA LEMAIRE: Yeah, but it was not that serious except that I had a shoulder dislocation and a small fracture.
SHANOOR SEERVAI: Wow, that sounds serious to me.
NATACHA LEMAIRE: Well, yeah. Well, I couldn't walk home, that's for sure.
SHANOOR SEERVAI: Right.
NATACHA LEMAIRE: So I did go to the local clinic. It was in Vermont, in the ski station, and because I was lucky enough to have an American insurance, so I gave my card, and then nothing else was given to me in terms of information on prices.
And probably if they were asked they couldn't have answered because they don't know. I mean, they can't know. It's too complicated.
SHANOOR SEERVAI: What happened after you had your shoulder treated in Vermont?
NATACHA LEMAIRE: So, after that I went home, back to Boston, and I had two follow-up visits with an orthopedic surgeon. So not the same one, the one in Vermont, of course.
SHANOOR SEERVAI: Of course.
NATACHA LEMAIRE: And the first surprise was when I received the bill from the insurance. So the two follow-up visits were like three weeks apart. It was with the same physician, but in two different locations. One was close to my office and the other one was close to my home, so it was more convenient for me at that time.
And the bill was not the same, and from my point of view it was exactly the same visit and I could not understand why it was not coded the same, and why the prices were different. The coverage different and my out-of-pocket money different; everything was different.
SHANOOR SEERVAI: So, if you don't mind my asking, do you remember what the two visits cost?
NATACHA LEMAIRE: One was like, you know, $300 and the other was $400 and something.
SHANOOR SEERVAI: Okay. So you were surprised that there was different costs for what, in your mind, was the same thing.
And throughout this whole procedure you had no idea how much it was going to cost you.
NATACHA LEMAIRE: Yes. And it is quite stressful not to know. Because then this is only the medical part. Then I had to do some physical therapy because I couldn't move my arm.
And you feel guilty because you think, "Wow, what have I done? Maybe something is wrong and I won't be covered."
SHANOOR SEERVAI: And the guilt is because of the cost? How much did each session of physical therapy cost you?
NATACHA LEMAIRE: The cost for the insurance was $200 and for me it was $30. So $230 in total.
In France, one session is 16 euros and after insurance the deductible is — for you it's ridiculous, it's 50 cents.
SHANOOR SEERVAI: That's a difference of night and day. Fifty cents versus $30.
How's your arm now? Are you fully recovered? Is everything okay?
NATACHA LEMAIRE: Yes. Yes. That's the good news. It was worth it.
Health Coverage in France
SHANOOR SEERVAI: So because you had insurance, at least the care you received was good quality. But it strikes me that you were here in the United States to do research at a university. You had insurance. What do you think about our health care system for those without insurance?
NATACHA LEMAIRE: So, as I understand it, for deprived people, when they have — they can benefit from Medicaid or other kinds of programs like this one, then it's fine because they don't pay. But for just above the threshold, then they probably can't afford any insurance and then the result is that they pay more. For me, that was something not acceptable.
SHANOOR SEERVAI: And why was it so unacceptable to you? What happens to people in France who can't afford insurance?
NATACHA LEMAIRE: You don't really have that question because insurance is compulsory. So one way or another -- either you have it because you work or you don't work, but you are on welfare or you have another situation, and then there is a way for you to be insured.
SHANOOR SEERVAI: Wow, so in France, everyone is covered. If you are on welfare do you automatically get insurance? Because in the U.S. you need to show that you're eligible for Medicaid and then you get Medicaid. And that eligibility varies by state.
Some people here, if they're just above the threshold, maybe they — maybe they work as freelancers, so they don't have an employer to provide insurance, but they are not getting support from the government to buy their own insurance. And so, especially if they're young and healthy, they just won't have insurance because they can't really afford it. Would that happen in France?
NATACHA LEMAIRE: No, because you have a specific insurance for people who are self-employed.
SHANOOR SEERVAI: Okay.
NATACHA LEMAIRE: And they have to be insured. It's compulsory, and it doesn't cost that much.
SHANOOR SEERVAI: Right.
NATACHA LEMAIRE: And because the level of the premiums are sustainable, affordable, it's not really an issue.
SHANOOR SEERVAI: So having health care is not an option. Your employer just pays it, or there’s some other way to get it, and then you don't even really think about it.
NATACHA LEMAIRE: Exactly. You don't think about it.
SHANOOR SEERVAI: Wow.
NATACHA LEMAIRE: And in the U.S., you have to think about it and this is not — this is not good because then you don't have the same behavior concerning your health, your own health, because first you think money and then what you should do. And it should be the other way around.
Thinking About Health, Thinking About Money
SHANOOR SEERVAI: Did you feel that when you were here? You were thinking more about money than your own health?
NATACHA LEMAIRE: Yes. Yes, I did.
I was happy to go home, just not to have to think about that, and for me, for my husband, for my kids, for all of us. Because instead of saying, "Okay, I don't know what I have, but I will go and see a doctor to check that everything is fine." Over there it was, "Okay, let's try to do the diagnosis myself."
SHANOOR SEERVAI: But that time your son had to go to hospital from school, you couldn’t do the diagnosis yourself. And he ended up in the hospital, and you said you received a bill — by mistake — for $3,500. Was there a point when you and your husband thought that you might actually have to pay that amount?
NATACHA LEMAIRE: Yes. The first — actually, it's my husband who opened the envelope and said, "I will never pay that. I don't want to pay that. I can't" — I mean, not for 10 minutes or, you know, 20 minutes total when you count everything. It's just not possible.
And then we realized that it was not the good rate, so then we were relieved, but relieved not completely because we didn't know how much the insured rate would be. So that took another week or so, and then we received the second one, but because of the deductible, we had to pay $500 out of pocket and we thought that that was also a lot and too much.
And we were — you know, we were mad. We were thinking it should be that way. It's too expensive. It's much too expensive.
SHANOOR SEERVAI: And it sort of creates a double — again, there's the anger and the stress about the money and then the stress about your child's health.
NATACHA LEMAIRE: Yeah. But as for the stress for the kid's health, we knew from the same evening that he was fine. So then it was only the cost thing, because for him, everything was back to normal after that quite quickly. That was the good news.
And at the end, you know, when they went to play on the playground and — so we told them, "Okay, so be careful please. We don't want to go to the hospital," and that was the kind of the joke of the family, that we didn't want to go back to the hospital, none of us.
SHANOOR SEERVAI: [laughs] Well, I'm glad — I'm glad your kids could see the humor.
NATACHA LEMAIRE: Yes.
SHANOOR SEERVAI: So, I mean, it sounds like you had — it sounds like you had a challenging time here, but if there was one thing that you could say was the hardest thing to navigate about the health care system in America, what would that be?
NATACHA LEMAIRE: The fact that you don't know the price of the service beforehand. It's the worst for me.
SHANOOR SEERVAI: So what you’re saying it’s not only that care is expensive, but that there’s so much uncertainty around what it will cost.
Now that you're back home in France, what are you most relieved about?
NATACHA LEMAIRE: Not to have to think about it. It's just not an issue, so we don't — it's not a worry. So if we have something, then we can — you know, we can go and see a physician and then see afterwards if something has to be done. We don't wait.
SHANOOR SEERVAI: Is there anything, Natacha, that you miss about the U.S. system?
NATACHA LEMAIRE: From my experience, the kindness of the people, of the health care professionals. I mean, we noticed that and probably it was a little different than it is here in my country. So I would miss that.
SHANOOR SEERVAI: Well, I think I know what your answer is going to be for this last question, but I'll ask you anyway: If you had to choose between the health care system in France and the health care system in America, which one would it be?
NATACHA LEMAIRE: You guessed right, so it would be the France system. But what I can say is that I love it more since I've been in the U.S. because we take it for granted here and I did not realize all of that, and now that I've experienced another system I do love it even more.
SHANOOR SEERVAI: Well, that's great to hear and that's a great note to end on. I'm happy that your shoulder and your arm are fine. I'm obviously happy that your children are safe and thank you so much for taking the time to speak with us today.
NATACHA LEMAIRE: Thank you.
SHANOOR SEERVAI: And that’s a wrap — thank you all for listening to The Dose. We’ll be back next week with more stories about health care in different parts of the world.