health and presidential

Health: a guide for French people who want to vote and know why.

Do the general statements made in the health programmes of the two candidates running for President 2017 reflect a lack of knowledge of the real situation? A few measures will not be enough to repair our system. Its survival depends on its reorganization. And for that, two conditions must be met: a real assessment of its failures and the ambition to rebuild our healthcare system into one of the best in the world. I invite you to take a plunge into the programs of Emmanuel Macron and Mr. Le Pen, in order to forge a conviction based on evidence, as we do in medicine.

Medical desertification

C’is the leading subject for the French who best translate this two-speed medicine that I denounce in the book "Cheers, the threatened treasure". They are not wrong because, behind this word, we find most of the causes that generate inequalities in the face of disease and accidents in life: the number of health professionals per inhabitant, which is excessive in some city centres, insufficient to the point of absence in other territories, but also the disappearance of small public hospitals, the consequences of the recurrent overcrowding of emergency departments, mortality due to dysfunctions in the system and its organisation...
To combat desertification, Marine Le Pen wishes to increase the numerus clausus, i.e. the number of places open to medical students; Emmanuel Macron has decided against this solution.
But is it one? It takes nine years to train a general practitioner, a surgeon eleven. Can we wait for these times to remedy desertification? Obviously not, because the projections made by health demographers [1] and by the National Order of Physicians [2] show a constant increase in the number of territories concerned. This is due to the age pyramid among doctors, which shows that the peak of retirements will be reached in five to six years. This is too early in relation to the time required for training. But more than that, what will the number of doctors change with regard to the issue of desertification? The answer is nothing or on the margin. France has never counted so many, almost twice as many as forty years ago, except that fewer and fewer people are choosing general medicine and those who do so are settling in areas that are already well provided for.
So what will make young doctors suddenly want to move to the Vendée or La Manche (departments with the fewest doctors per inhabitant) or to peri-urban areas? To this question, the two candidates answer in chorus: "Maison de santé!", which only Emmanuel Macron is counting and wants to double the number. Yes, the maisons de santé are a lever; no, they are not enough for young GPs to settle in these already under-endowed areas. The number of nursing homes that are unoccupied, because they were designed without consultation with the professionals concerned or because they are only part of a real estate programme, is considerable.
Still against desertification, Marine Le Pen adds "an internship in the areas concerned". Except that these internships in general medicine already exist and that they were even reinforced in the last law called Modernisation; except that to host these internships, one must have the qualification of teaching general practitioner and that, as luck would have it, there are few or none in the areas concerned!

Survival of public hospitals

Desertification is certainly primarily due to general practitioners, but it is also expressed by the closure of small and medium-sized public hospitals in favour of clinics often owned by pension funds.
On this subject, Marine Le Pen wants to "maintain as many community hospitals as possible and increase the number of hospital civil servants". She is well aware that the issue of public hospitals in small and medium-sized towns is a major concern for their inhabitants and that their restructuring, mergers or closures mobilize them more than any other issue.
The problem is that the proposed remedy is not the right one. The survival of these institutions is directly related to the existence of private clinics. The head-on competition is expressed first of all by the continuous aspiration of young graduates by the private sector which causes the asphyxiation of public hospital services where vacancy rates can reach 41% in certain specialties. Does Madame Le Pen intend to prohibit young graduates from settling wherever they wish? There is no doubt that the reaction of professionals, for whom freedom of establishment is essential, will be strong, and it is to be feared that the result of this measure will be worse than what it is supposed to fight against. Unless it intends to pay public surgeons, doctors, nurses and nursing auxiliaries the same price as in the private sector, but then we need to be told where the money will come from - salaries are already the largest single item in public spending. According to economists, this measure would increase the hospital health budget from 30 to 40%. In other words, impossible.
More realistic and concrete, Emmanuel Macron wants to invest 5 billion in the transformation of our city medicine and our hospitals, but does not express an opinion on the sustainability of public hospitals in the face of private supply.

Reimbursement of health expenses

The two candidates find themselves on the reimbursement of health expenses, insufficient in their eyes. Their convergence stops there. For Marine Le Pen, it is a question of "guaranteeing social security for all French people as well as the reimbursement of all the risks covered by the health insurance". For Emmanuel Macron, the aim is to achieve "100% for glasses, hearing aids and dental prostheses by 2022 in conjunction with mutual insurance companies and health professionals". At least for the latter, we have a deadline, for the rest the copies are small. The estimated cost of the measure proposed by Emmanuel Macron is 5 billion, that of Marine Le Pen at least double. Because what the administration modestly calls the RACs (Remains to be paid) does not only cover the three devices mentioned by En marche. Thus, the people most affected by these RACs are first and foremost disabled and ageing people. Just one example: an electric wheelchair, as indispensable as a pair of glasses and more than a dental implant, leaves an average RAC of 3,000 euros, which explains why, for the same population, we have 30% fewer electric wheelchairs than our German neighbours!

Candidates, get out your calculators

But in all these proposals, one thing is more worrying. The approximate or non-existent quantification of these measures, particularly at the Front National. Professionals will find it hard to understand-and even harder to believe-that while we are cutting staff and limiting spending everywhere, we can suddenly wave a magic wand and put $5 billion on the table to finance the RACs, increase the hospital payroll from 30 to 40%, double the number of nursing homes, raise the number of claususus in faculties that are already saturated...
Perhaps the Front National is counting on the one billion in State Medical Aid (AME) that the "clandestine" people are costing and that it wants to abolish. The account will not be there for the simple reason that the use of the AME concerns as many French people as foreigners, with or without papers.
This proposal of the lepenist program is the exemplary illustration that humanism, a French value if ever there was one and of which this party should therefore flatter itself, is alien to its principles. It demonstrates that its xenophobia takes precedence over the most basic public health. One example is tuberculosis, which continues to be rampant in France. In the vast majority of cases, the carriers of the bacillus are undocumented immigrants. Treated, they are no longer contagious, untreated, a cough in the metro or bus will be likely to transmit the disease.
Finally, how can Mrs Le Pen imagine that doctors will refuse care to someone because they are undocumented and without money? This measure would call into question the Hippocratic oath signed by all doctors, so much so that it is null and void.
Above all, it perfectly illustrates the gap between the two official programmes. Their visions of the world are radically different. One is universalist in line with our model conceived by the National Council of Resistance, even if one would like to find as much breath and ambition in it, the other is closed and inward-looking, the opposite of what underpins our social model.

The Forgotten

Some major themes absent from the programmes. Nothing on the safety of medicines, which is the leading cause of death in the dysfunctions of our health system and a source of growing mistrust, even rejection, on the part of the French, who are expressing themselves, for example, with regard to vaccination.
There is also nothing about home care for dependent elderly people, which will be a major challenge for our society over the next twenty years.
But, above all, nothing about the essential reorganization of care, from the first line to hospitals, including emergency rooms, the adaptation of professions and their training to the new needs of the population and the new tools of medicine.
Time is running out to finally get the candidates, the answers that patients, policyholders and healthcare professionals are waiting for. And since the subject is complex, I am willing, in the final stretch of this campaign, to lend an expert ear, capable of detecting omissions and untruths. I hope that this reflection will suggest some questions to ask the two players in the second round of the presidential election.
Antoine Vial
Antoine Vial is a public health expert. From 2006 to 2012, he was a member of the "Quality and dissemination of medical information" commission for the Haute autorité de santé. He is a member of the board of directors of the magazine Prescrire, co-chairman of the Santé-Solidarité club of Prospective 2100, a member of the Société française de santé publique and co-founder of the Forum des Living Labs en santé et autonomie.
1] Health: abandoned territories. Emmanuel Vigneron, Le Monde 31 March 2017.



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