When I described surprise medical bills to experts who focus on different western-European countries’ health systems, they had no idea what I was talking about. “What is a surprise medical bill?” said Sophia Schlette, a public-health expert and a former senior adviser at Berlin’s National Association of Statutory Health Insurance Physicians. “Seriously, they don’t happen here.”
Almost all Germans are covered by a variety of health insurance, such as “sickness funds,” which are financed through taxes. Almost all doctors and hospitals accept these plans. About 90 percent of Germans never see a bill for their doctor visits, and the rest are covered by private insurance, which usually reimburses whatever they get charged. According to the researchers Roosa Tikkanen and Robin Osborn at the Commonwealth Fund, there’s a flat co-pay for people who are hospitalized, capped at a maximum of 280 euros—or about $315—for a 28-day stay. And doctors, too, are not allowed to charge more than the payment rates that are negotiated between the sickness funds and the doctors’ associations. A very small number of the country’s physicians are private and don’t accept the sickness funds, but they have to tell patients how much they’ll charge before a patient is treated, removing the surprise element.
In France, there are no provider networks, so no doctor can be “out-of-network.” Doctors’ associations negotiate their fees with the universal public health-insurance program every few years. As a result, says Paul Dutton, a history professor at Northern Arizona University who has studied the French system, “I’ve walked into an office [in France] with my kids where it’s just a receptionist and a doctor. There’s not these back-office wars” over what to charge patients.
Some French doctors choose to bill above the government-mandated amount, and this can indeed lead to extra medical bills, Tikkanen and Osborn told me. But 95 percent of the French population also has private secondary insurance—often included in an employer’s benefit package—that helps cover the doctors who “extra bill.” Doctors have to post their fees on their walls, and you can ask how much the visit will be before you book an appointment. In the United States, it’s easier to find out how much it costs to park at a hospital than to get an electrocardiogram there.
In France, the general rule is “the sicker you are, the better your coverage,” Dutton says. If you get hit by a car, the public health insurer picks up more of your tab than, say, if you’re getting acne treatment.