nation, and negotiates the labor contracts of
in the future. There is no consensus on what
medical staff. The Italian Constitution was
French health care reform would look like.
changed in 2001 such that the national gov-
Still, some 65 percent of French adults
ernment now sets the "essential levels of care"
believe that reform is "urgent," and another
20 percent believe reform is "desirable."86
regions must meet, but regional governments
still control their own autonomous budgets
Moreover there is growing dissatisfaction
and distribute resources to the local level.
with the French welfare state--of which the
In theory, under the "fiscal federalist" provi-
health care system is a significant part--and
sions of this reform, discretionary central
the level of taxes necessary to support it. The
transfers should have dropped sharply, local
recent election of French president Nicolas
tax bases and tax sharing should have
Sarkozy is widely regarded as a reflection of
this new attitude.87 Indeed, the new French
increased, and "equalizing" transfers should
have been standardized and linked to objec-
government has made a crackdown on health
care spending one of its top priorities..88
tives for controlling costs and increasing quali-
ty. However, poorer regions and powerful spe-
To sum up: the French health care system
cial interests have strongly resisted these
clearly works better than most national health
changes. Reform therefore remains incom-
care systems. Despite some problems, France
plete, and financial transfers from the central
has generally avoided the rationing inherent in
government are still based on historical spend-
other systems. However, the program is threat-
ing patterns.90
ened by increasing costs and may be forced to
resort to rationing in the future.
Thus, while the national Ministry of Health
The French system works in part because it
continues to outline funding needs based on
has incorporated many of the characteristics
weighted capitation and past spending, recent
that Michael Moore and other supporters of
reforms have shifted more and more power
national health care dislike most about the
and responsibility to regional governments
U.S. system. France imposes substantial cost
who set their own budgets. The regions estab-
sharing on patients in order to discourage
lish one or more Local Health Authorities,
over-utilization, relies heavily on a relatively
which are responsible for the provision of care
unregulated private insurance market to fill
either through government-run hospitals and
gaps in coverage, and allows consumers to pay
clinics or by contracting with private provid-
ers.91 It should be noted that governance in
extra for better or additional care, creating a
two-tier system.
Italy is often as much art as science, and
Although Italy
This is clearly not the commonly por-
regions frequently fail to implement rules,
spends a
trayed style of national health care.
guidelines, reimbursement schedules, and
budgets set by the central government.92
relatively low
Financing comes from both payroll taxes
percentage of
Italy
and general revenues. Payroll taxes have a
GDP on health
regressive structure, starting at 10.6 percent of
the first €20,660 of gross income and decreas-
Italy's national health care system is rated
€
care, expenditures
ing to 4.6 percent of income between €€20,661
second in the world by the WHO.89 Yet a clos-
have been rising
and €77,480. The remainder of funding comes
er examination shows the system to be deeply
€
from both federal and regional general taxa-
troubled, plagued with crippling bureaucra-
rapidly in recent
tion, including income and value-added
cy, mismanagement and general disorganiza-
years and have
taxes.93 The central government redistributes
tion, spiraling costs, and long waiting lists.
consistently
Generally, the Italian system is similar to
resources to compensate to some degree for
the British National Health Service but enjoys
inequalities among regions. Even so, most
exceeded
more decentralization. The central govern-
regional health authorities run significant
government
ment sets goals on how money should be
deficits. Overall, regional deficits top 1.8 per-
cent of GDP.94
forecasts.
spent, monitors the overall health status of the
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