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The French Health Care System

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The French Health Care System The french health care system The french health care system VICTOR RODWIN PROFESSOR OF HEALTH POLICY AND MANAGEMENT WAGNER SCHOOL OF PUBLIC SERVICE, NEW YORK UNIVERSITY NEW YORK, USA ABSTRACT: The French health care system is a model of national health insurance (NHI) that provides health care coverage to all legal residents. It is an example of public social security and private health care financing, combined with a public-private mix in the provision of health care services. The French health care system reflects three underlying political values: liberalism, pluralism and solidarity. This article provides a brief overview of how French NHI evolved since World War II; its financing health care organization and coverage; and most importantly, its overall performance. ntroduction. Evolution, coverage, financing and organization The French health care system is a model of national health Evolution: French NHI evolved in stages and in response to Iinsurance (NHI) that provides health care coverage to all legal demands for extension of coverage. Following its original passage, residents. It is not an example of socialized medicine, e.g. Cuba. in 1928, the NHI program covered salaried workers in industry and It is not an example of a national health service, as in the United commerce whose wages were under a low ceiling (Galant, 1955). Kingdom, nor is it an instance of a government-run health care In 1945, NHI was extended to all industrial and commercial workers system like the United States Veterans Health Administration. and their families, irrespective of wage levels. The extension of French NHI, in contrast, is an example of public, social security and coverage took the rest of the century to complete. In 1961, farmers private health care financing, combined with a public-private mix in and agricultural workers were covered; in 1966, independent the provision of health care services. professionals were brought into the system; in 1974 another law The French health care system reflects three underlying political proclaimed that NHI should be universal. It wasn’t until January values (Rodwin, 1981): 2000 that comprehensive first-dollar health insurance coverage 1. liberalism, in the sense of giving patients free choice of was granted to the remaining uninsured population, on the basis of doctors and hospitals; residence in France (Boisguerin, 2002). 2. pluralism, in offering diverse health care delivery options NHI forms an integral part of France’s Social Security system, ranging from private fee-for-service practice, health centers which is typically referred to by means of an agrarian metaphor, and outpatient hospital consultations for ambulatory care, as a set of three sprouting branches: 1) pensions; 2) family through a range of public, non-profit and for-profit hospitals; allowances; 3) health insurance and workplace accident coverage 3. solidarity, in the sense of having those with greater wealth (Damon and Ferras, 2015). The first two are managed by a single and better health finance services for those who are less national fund whereas the third branch is run by three main NHI well-off and in poorer health. funds: for Salaried Workers (CNAMTS); for farmers and agricultural In practice, the French health system represents a delicate workers (MSA); and for independent Professionals (RSI) (Bras and balance between NHI and private fee-for-service practice – la Tabuteau, 2015). In addition, there are eleven smaller funds for médecine libérale (Rodwin, 2003; Rodwin and LePen, 2004; Steffen, specific occupations and their dependents, each defending their 2010). The tensions involved in achieving universalism, respecting “rightfully earned” entitlements. The CNAMTS covers 86 percent liberalism and meeting the challenge of rising inequalities are often of legal residents in France which includes salaried workers, those highlighted in attempting to characterize the distinguishing features recently brought into the system because they were uninsured, of French NHI (Nay et. al. 2016; Steffen 2016). Also, the question and the beneficiaries of seven of the smaller funds administered of whether the system is sustainable, recurs with regularity (Rodwin by CNAMTS. and contributors, 2006). All NHI funds are legally private organizations responsible for In this article, I provide a brief overview of how French NHI the provision of a public service. In practice, they are quasi-public evolved since World War II; its financing, health care organization organizations supervised by the government Ministry that oversees and coverage; and most importantly, its overall performance. French Social Security. The main NHI funds have a network of local World Hospitals and Health Services - Universal Health Coverage (UHC): Making progress towards the 2030 targets Vol. 54 No. 1 49 Universal Health Coverage (UHC): Making progress towards the 2030 targets and regional funds that process reimbursement checks for health These indicators, however, are not sufficient for assessing the care providers and/or patients, look out for fraud and abuse, and system’s performance, because they reflect many other important provide a range of customer services for their beneficiaries. determinants of health, e.g. poverty rates (Figs. 1-2); other socio- Coverage and Benefits: French NHI covers services ranging economic disparities; maternal and child health programs; work from hospital care, outpatient services, prescription drugs and family policies; and nutrition. Although the U.S. spends more (including homeopathic products), spa treatments, nursing home on health care as a share of GDP, than any other nation, France care, cash benefits, and to a lesser extent, dental and vision care. spends a significantly higher share of its GDP on social service Small differences in coverage remain among different NHI funds. programs, particularly on family support and employment training Smaller funds with older, higher-risk populations, e.g. farmers, programs (Fig. 3). An important hypothesis to investigate is whether agricultural workers and miners, are subsidized by the CNAMTS, France’s government spending on these programs contributes to as well as by the state, on grounds of what is termed “demographic the population’s impressive population health status. compensation.” Retirees and the unemployed are automatically covered by funds according to their occupational categories. Health system indicators Financing: As of 2016, public health care expenditures France’s claim to fame with respect to health system accounted for 79 percent of total health care spending (DRESS, performance is its top ranking among wealthy OECD nations, 2016). Private voluntary health insurance (VHI) accounted for based on its success in averting deaths from a range of curable another 13 percent and out-of-pocket payments around 8 percent. cancers, pneumonia, ischemic heart disease, maternal deaths in Of the total public portion, social security payroll taxes accounted childbirth, and a host of other causes of mortality considered to be for 64 percent of the total. The remainder was financed by a “amenable to health care interventions.” Avoidable mortality (AM) national income tax on all earnings, including dividends and interest attempts to capture the extent to which deaths under the age of 75 from capital (16%), revenues from a tax on tobacco, alcohol, the years would not have occurred, had the population benefitted from pharmaceutical industry and private voluntary health insurance access to effective disease prevention programs, primary care, as (VHI) (12%), state subsidies (2%) and contributions from other well as specialty services. branches of social security (6%). Based on a comparison of avoidable mortality among 19 OECD Health Care Organization: Liberalism is correctly invoked as nations, France has the lowest rate (ranks #1) and the U.S. has underpinning the medical profession’s attachment to cost-sharing the highest rate (ranks #19) (Nolte and McKee, 2008). Moreover, and selected elements of la médecine libérale (private fee-for- between 1999-2007, the percentage decline in AM in France service practice): selection of the physician by the patient, freedom (27.7%) was higher than in the U.S. (18.5%) (Nolte and McKee, for physicians to practice wherever they choose. Likewise, the 2012). Based on these findings, Nolte and McKee estimate that if diverse forms of practice in ambulatory care – private office-based the U.S. were to achieve levels of AM of the three top-performing arrangements that still prevail, along with growing numbers of countries (France, Japan and Australia), about 101,000 deaths health care centers and hospital-based consultations – reflect the could be avoided. importance of pluralism in French medical practice. As for hospitals, An exclusive focus on AM does not allow one to disentangle the most acute beds are public (two-thirds), with the remaining third consequences of poor access to disease prevention versus primary consisting of private beds divided among commercial for-profit or specialty health care services. Thus, it is useful to consider other and private not-for profit, usually affiliated with the public hospital indicators that capture the consequences of barriers in access to service. primary and specialty care (Gusmano and Rodwin, 2010). The first is well-established – hospital discharges for ambulatory care sensitive Performance conditions (ACSC). It measures hospitalizations for exacerbations The French health care system is worthy of attention from
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