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American voters say healthcare is one of the top two or three issues they want the next president to address. Nearly one in five Americans is uninsured. But for most Western Europeans, the idea that everyone has health insurance is something that's taken for granted.

You might assume that people with universal coverage have to give up the right to choose their own doctors and hospitals. But in France, patients have universal coverage and lots of choice. And France is the latest stop for our series on European healthcare.

NPR's Joseph Shapiro went to France. Where exactly did you go?

JOSEPH SHAPIRO: I started in Paris, but then I went down to this beautiful countryside in the southwest France.

NORRIS: Oh, you're making me jealous. What did you find?

SHAPIRO: I found a country that has a universal insurance program, and it's funded mostly with payroll and income taxes, and that universal insurance does pay for almost all the care people get. But not all, so there's also private insurance to pay for the rest. And that extra insurance is affordable. Almost everyone has it. And in fact, usually it's paid for by your employer in part or totally.

NORRIS: So how does that compare to what we find here, where people say it's often not affordable?

SHAPIRO: Well, workers in France are required to pay what adds up to about 21 percent of their income into this national health care system. But employers do pick up about half of that. And so although Americans, we don't pay as much in taxes, Americans do end up paying more for health care when you add in the costs of buying insurance and the higher out of pocket expenses for medicines, doctors, hospitals.

France's health care system is one of the most expensive in the world, but the U.S. has the most expensive. And here we spend about twice as much per person compared to France.

NORRIS: What accounts for that difference?

SHAPIRO: In France, they control costs, doctors get paid less, and government sets most hospital costs.

NORRIS: Joe, what struck you most, other than costs, about the differences between the U.S. and France?

SHAPIRO: I think it's that in France, the sicker you are, the more the government pays for. I want to show you what we found when we spent time with two people in France who are dealing right now with difficult cancers.

NORRIS: Let's take a listen.

SHAPIRO: We met Annie Hubert of the Bergonie Institute, a cancer clinic in Bordeaux. She came for a CAT Scan, which she gets every four months to check the size of her tumors.

ANNIE HUBERT: This is what you call a day hospital, where you have your chemotherapy. There is great privacy, which is not often the case with chemotherapy. Often it looks like, you know, the cow is being put in. And here privacy is really important, especially.

SHAPIRO: She's had breast cancer years before, then four years ago it came back, creeping into her bones, liver and lungs. Hubert is thin. Her skin is pasty. Her eyes are bright.

HUBERT: I live with cancer now for 14 years. You're really used to it. And for four years, you know, these very regular checkups, I'm used to it too. This is part of life. If I were 30, I suppose I would see things differently. But I'm 67. So everybody has to die one day. I'll probably die from this disease. I don't know when. I live with it.

SHAPIRO: And live with it she has, and as normally as possible. Today she's brought a copy of her most recent book and inscribed it for a friend. Hubert is an anthropologist. After her cancer, she got a grant from the French government to study how doctors communicate with patients.

HUBERT: I'm a good anthropologist because I'm doing what the French call observation participant. Nothing equals experience to understand things.

SHAPIRO: Maybe it's Hubert's upbeat attitude that allows her to keep doing the work she loves, but it's also in no small part thanks to France's health care system. Everyone in France gets health insurance. And when someone has a difficult disease like cancer, the national health system steps in and pays for 100 percent of their care.

Unlike in the U.S., you don't need to stay in your job to keep your insurance, nor is there a lifetime limit on how much treatment a long-term survivor like Annie Hubert can get.

A young doctor in a white lab coat comes quietly into the room.

HUBERT: This is my doctor.

Unidentified Man: Good morning (Speaking French)

SHAPIRO: Here's another thing that stands out about France. Cancer care is well organized. To treat patients, a hospital or clinic has to prove it meets national standards for high-level care. At this clinic, oncologist Marc Dublet and his team coordinate every aspect of Hubert's care. She can call the doctor any time with any question or concern. And although this is a country where doctors for a long time simply told patients what to do, that's changing.

MARC DUBLET: Now we discuss more and more with patient and we decide together what treatment to do.

HUBERT: You're not considered as, you know, an illiterate something, that, you know, you're going to be treated as, you know, like a sheep in the country.

SHAPIRO: Nor has Hubert had to fight with insurance companies or worry about getting access to her expensive therapies.

HUBERT: Never ever for any, which is incredible. I mean, I have friends who have cancer and had cancer in America, and they can't believe it. It's a tremendous difference. Now I have a son-in-law who has MS.

SHAPIRO: That son-in-law and her daughter live in California. He has multiple sclerosis.

HUBERT: Even with good insurance he still has to spend, you know, several hundred dollars a month for his treatment.

SHAPIRO: At France's new National Cancer Institute, Dr. Fabian Calvo was in charge of research. He talks about something unheard of in the U.S. In France, every cancer patient can get any drug, including the most expensive, and even experimental ones that are still being tested.

FABIAN CALVO: As soon as there is a breakthrough, even if the drug has not obtained the approval, you can get access for that.

SHAPIRO: That access to any medication is one reason why France, in a study this year, was rated the best among industrialized nations at preventing avoidable deaths. The US came in last. There's another difference. In France, even most people who aren't citizens are covered by the Universal Insurance Program, like Brian Coote. Three years ago, he and his wife Julie retired early and moved from outside London to southwest France.

BRIAN COOTE: Well, this was an old farmhouse. We don't quite know how old it is, but probably two or 300 hundred years. And we've completely renovated it.

SHAPIRO: From the stone house on a hill, Coote looks across the farms of the gently rolling Dordogne Valley. The Cootes rent out cottages to tourists. He's 57 and athletic. He's an avid hiker. But he started having stomach problems in the spring of last year. At first, his rural general practitioner dismissed it as nothing serious.

COOTE: At the end of June, I'm doing a big walk in the Pyrenees Mountains, and I had to stop after three days and come home. And that sort of said, well, there's something here that's not normal for me.

SHAPIRO: It took until mid-September to get the diagnosis that should have come months earlier: He had colon cancer. Coote faults his first doctor. But he says once he got to a surgeon, he's received excellent care. Now there's even a nurse who makes home visits. She drives all the way to this farmhouse in the country where Brian and Julie live.

COOTE: She knows me well. When I came out of hospital after the operation, she was here every day to check the dressing and...

JULIE COOTE: She also comes to do a blood test just before the chemo. If chemo is on a Monday, she comes on a Saturday to take the blood test.

SHAPIRO: Still, in a country that's so generous, it's hard to control rising health care costs. Last year, the National Health Insurance fund ran nearly $9 billion in deficit. The government looked for ways to cut costs. Last fall, just as Brian Coote began his treatment, the government announced it would no longer would pay for foreign retirees like the Cootes.

COOTE: I did, in the back of my head, kind of think this is ludicrous. They cannot possibly do it. It means that people are going to die.

There are some 200,000 British expatriates living in France, and their numbers give them power. They petitioned and protested, and in January, the government reversed itself. Many British expatriates say they're here in part because they don't trust the British health care system. Brian Coote isn't one of them, but he does appreciate the health care he has received since his surgery in France. It allows him to continue to live in this stunning corner of the world, even as he battles a difficult cancer.

Joseph Shapiro, NPR News.

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