France’s vision of universal healthcare and America’s health insurance premium-reliant system are worlds apart. On October 1 2025, the US Federal Government shut down after an insufficient number of Democrat votes amid disputes over health policy led to a federal government budget deadlock
The longest shutdown in US history could have had dramatic consequences for part of the population, particularly for millions of Americans who would have lost their health insurance. President Trump is on a mission to dismantle policies introduced by Barack Obama (and maintained under the Biden administration) to improve access to health insurance for the most disadvantaged.
On top of the anticipated decline is the incredibly questionable policy of US Secretary of State for Health, Robert Francis Kennedy Jr, and his highly controversial views on vaccines.
Meanwhile, despite a 17.5 billion deficit and a need for reform, in terms of quality and access to medical care, France’s Assurance Maladie national healthcare system remains a “land of plenty”.
Efficient medical care, ‘à la française’
A good starting point for explaining France’s national health service to Americans would be to step back in time.
In 1939, a US citizen’s life expectancy at birth was seven years higher than for a French citizen. Things have changed since then. In 2024, it was more than three and a half years lower: life expectancy stood at 79 in the United States compared to 82.5 in France. In 2025, however, healthcare expenditure per capita was equivalent to 12,627 euros in the United States (14,885 dollars), and 6,249 euros in France (7,367 dollars).
At national level, this translates into so-called health costs (mainly medical fees), representing 17.2% of GDP in the US and 11.4% in France. While changes in life expectancy are linked to lifestyle and eating habits (leading to obesity and diabetes), the effectiveness of medicine is playing an increasingly important role.
It is likely that the quality of healthcare for the majority of people is both better and more accessible in France.
When it comes to paying for medical care, France has a simple system: it is a country where you are covered by health insurance from birth. All legal residents are automatically registered with the health insurance system and, therefore, receive free healthcare for the most serious conditions, or care that is largely reimbursed within the compulsory health insurance scheme and covered by top-up insurance plans.
In the US, there is a three-tier social security system: Medicare for the over 65s and people with disabilities, Medicaid for the poorest, and the Veterans Health Administration for veterans.
Healthsystemtracker
7.8% out-of-pocket expenses for French citizens
Thirty long-term serious conditions such as cancer, type 1 or 2 diabetes or psychiatric illnesses are fully covered (treatment is fully reimbursed) by the compulsory state health cover that is offered to all French citizens.
If we add top-up health insurance – now almost universal – patients in France actually only end up paying 7.8% of their healthcare costs. Admittedly, French citizens or their employers will have contributed in financing compulsory or top-up health insurance.
For most French people, there are few or no financial barriers to entry. These barriers have been further reduced for dental care, optical care and hearing care thanks to a universal policy implemented by Emmanuel Macron called “100% healthcare”.
On the whole the French system is more generous than those of comparable countries.
Patients are encouraged to register with a general practitioner with whom visits are then fully reimbursed. If they choose to consult a different health professional, it will only cost them a few euros more. Patients are can make same day appointments to see several specialists whose fees are largely reimbursed, that is unless they don’t charge rates higher than those set by the National Health Service (known as “excess fees”), a common practice in certain medical specialities.
France: a predominantly state-run health service
Like in the United States, France has public hospitals, private clinics and private non-profit clinics. All 31 of France’s university hospitals are state-funded.
France does, however have a higher percentage of private (for-profit) hospitals than the United States. In 2024, 33% of clinics in France were private compared to 20% in the US.
In France, private practice physicians are free to set up practice wherever they wish and are paid on a fee-for-service basis. In the majority of cases, doctors’ fees are set by the national health insurance system and are much lower than in the United States: 30 euros for a visit with a general practitioner in France, $150 in the United States, or 127 euros.
Strong French state regulation
It goes without saying that in France, the State is heavily involved in regulating its national health service.
Opening a pharmacy is impossible without administrative authorisation, for instance. The State, through its regional health agencies, controls all hospitals – public or private. It manages the register for all medical procedures, pricing and reimbursement rates for each medicine, X-ray or biological test a doctor prescribes. At national level, the State is responsible for appointing all directors and doctors in public hospitals, which employed nearly 1.1 million people at the end of 2021.
High-quality private establishments are present in France (they employed 315,000 people in 2022 and, I would again lay emphasis on how private doctors are free to set up their own practices and prescribe care as they see fit.
Despite everything, the French system is one of the most expensive in the Western world. Hospital stays account for a large proportion of expenditure. France has many specialists, and medication consumption is high.
TheAmerican system is is even more expensive, and, in reality, more inefficient because competition between private insurers does not lead to a reduction in the cost of services – as is often the case in a market economy – it results in inflation in insurance premiums. Backed firmly by their belief in the absolute and systematic benefits of all forms of competition, wealthy individuals in the United States take out insurance policies to cover the fees of renowned doctors and stays in luxury hospitals. In doing so, they ramp up the costs of medical goods and services.
The US healthcare system is, in essence, ‘inflationary’
Over time, US healthcare providers’ tariffs (having been made solvent by part of the demand) have increased, leading to inflation. The high expenditure of the US health service, which is an inherently inflationary system, compared to other Western countries, is mainly due to a difference in the pricing of medical goods and healthcare professionals’ fees.
The reforms during Barack Obama’s term in office did nothing to curb this inflation. Donald Trump says he wants to tackle this by putting pressure on drug prices in particular.
It is plain to see that universal health insurance allows for operational control over medical and hospital fees and the price of prescription drugs. This is the norm in OECD countries, such as France. This does not mean that doctors or nurses are poorly paid, or that there is no access to medical breakthroughs, but rather that regulation is safeguarded, i.e. not left to a market which, in the specific case of healthcare, mainly produces inflation.
Are the United States more socialist?
To conclude with a brief arithmetic demonstration: public health expenditure, financed by taxes and compulsory contributions, represents 43% of healthcare expenditure in the US, or 4,532 euros per capita per year (43% of the 10,517 euros in current healthcare expenses). In France, these expenses represent 79.4% or 4,195 euros or 4,863 dollars – 79.4% of 5,273 euros in current healthcare expenses per person per year, with the remainder being covered by patients themselves or their top-up health insurance plans.
In other words, US taxes provide more funding for the healthcare system in absolute terms! Can we safely say that this makes the United States more “socialist” in its approach? Obviously, there is no supporting evidence to suggest this, but it is clear that Americans pay twice for their healthcare: once through their taxes and a second time via their insurance premiums.
People in the US have long been aware of this and have become staunch supporters of universal health insurance, introduced by the late Senator Ted Kennedy, the youngest of the Kennedy brothers. The chances of such a reform making it onto the political agenda in the short term are nil because, to conclude with a quote from Marcel Proust’s Swann’s Way:
“The facts of life do not penetrate the sphere in which our beliefs are cherished; as it was not they that engendered those beliefs, so they are powerless to destroy them.”
Beliefs in the universal efficiency of the market are therefore as firm as they are costly, and are now more alive than ever.
