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The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States

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The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States INTERNATIONAL PERSPECTIVES FORUM The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States The French health system | Victor G. Rodwin, PhD, MPH combines universal coverage with a public–private mix of hospital and ambulatory care THE FRENCH HEALTH CARE out reforming the overall man- levels of resources (Table 2), and and a higher volume of service system has achieved sudden no- agement and organization of the a higher volume of service provi- provision than in the United toriety since it was ranked No. 1 health system. This strategy has sion (Table 3) than in the United States. Although the system 32 is far from perfect, its indica- by the World Health Organiza- exacerbated tensions among the States. There is wide access to 1 tors of health status and con- tion in 2000. Although the state, the NHI system, and comprehensive health services sumer satisfaction are high; methodology used by this assess- health care professionals (princi- for a population that is, on aver- its expenditures, as a share of ment has been criticized in the pally physicians), tensions that age, older than that of the United gross domestic product, are Journal and elsewhere,2–5 indi- have long characterized the po- States, and yet France’s health far lower than in the United cators of overall satisfaction and litical evolution of French expenditures in 2000 were States; and patients have an health status support the view NHI.13–15 equal to 9.5% of its gross domes- extraordinary degree of choice that France’s health care system, Although the French ideal is tic product (GDP) compared with among providers. while not the best according to now subject to more critical scru- 13.0% of GDP in the United Lessons for the United these criteria, is impressive and tiny by politicians, the system States.17 States include the importance deserves attention by anyone in- functions well and remains an The health system in France is of government’s role in pro- viding a statutory framework terested in rekindling health important model for the United dominated by solo-based, fee-for- for universal health insurance; care reform in the United States States. After more than a half service private practice for ambu- recognition that piecemeal re- (Table 1). French politicians century of struggle, in January latory care and public hospitals form can broaden a partial pro- have defended their health sys- 2000, France covered the re- for acute institutional care, gram (like Medicare) to cover, tem as an ideal synthesis of soli- maining 1% of its population among which patients are free to eventually, the entire popula- darity and liberalism (a term un- that was uninsured and offered navigate and be reimbursed tion; and understanding that derstood in much of Europe to supplementary coverage to 8% under NHI. All residents are au- universal coverage can be mean market-based economic of its population below an in- tomatically enrolled with an in- achieved without excluding pri- 16 systems), lying between Britain’s come ceiling. This extension of surance fund based on their oc- vate insurers from the sup- “nationalized” health service, health insurance makes France cupational status. In addition, plementary insurance market. where there is too much ra- an interesting case of how to en- 90% of the population sub- (Am J Public Health. 2003;93: 31–37) tioning, and the United States’ sure universal coverage through scribes to supplementary health “competitive” system, where too incremental reform while main- insurance to cover other benefits many people have no health in- taining a sustainable system that not covered under NHI.33 An- surance. This view, however, is limits perceptions of health care other distinguishing feature of tempered by more sober ana- rationing and restrictions on pa- the French health system is its lysts who argue that excessive tient choice. Following an over- proprietary hospital sector, the centralization of decisionmaking view of the system, and an as- largest in Europe, which is acces- and chronic deficits incurred by sessment of its achievements, sible to all insured patients. Fi- French national health insurance problems, and reform, this article nally, there are no gatekeepers (NHI) require significant explores lessons for the United regulating access to specialists reform.9,10 States of the French experience and hospitals. Over the past 3 decades, suc- with NHI. French NHI evolved from a cessive governments have tin- 19th-century tradition of mutual kered with health care reform; THE FRENCH HEALTH aid societies to a post–World the most comprehensive plan CARE SYSTEM War II system of local demo- was Prime Minister Juppé’s in cratic management by “social 1996.11,12 Since then, whether The French health care system partners”—trade unions and governments were on the politi- combines universal coverage employer representatives—but it cal left or right, they have pur- with a public–private mix of hos- is increasingly controlled by the sued cost control policies with- pital and ambulatory care, higher French state.34 Although NHI January 2003, Vol 93, No. 1 | American Journal of Public Health Rodwin | Peer Reviewed | International Perspectives Forum | 31 INTERNATIONAL PERSPECTIVES FORUM TABLE 1—Health Status and Consumer Satisfaction Measures: France, United States, Germany, United Kingdom, Japan, and Italy France US Germany UK Japan Italy Health status Infant mortality (deaths/1000 live births), 1999a 4.3 7.2b 4.6 5.8 3.4 5.1 LEB (female), 1998a 82.2 79.4 80.5 79.7 84.0 81.6c LEB (male), 1998a 74.6 73.9 74.5 74.8 77.2 75.3c LE at 65 (female), 1997a 20.8 19.2 18.9 18.5 21.8 20.2 LE at 65 (male), 1997a 16.3 15.9 15.2 15.0 17.0 15.8 Severe disability-free life expectancy (female), 1990/1991d 14.8 NA NA 13.6 14.9 NA Severe disability-free life expectancy (male), 1990/1991d 18.1 NA NA 16.9 17.3 NA Potential years of life lost per 100000 population (female), 1993e 2262 3222 2713 2642 1914 2136 Potential years of life lost per 100000 population (male), 1993e 5832 6522 5752 4688 4003 4873 Consumer satisfaction, % Only minor changes needed, 1990f 41 10 41 27 29 12 Very satisfied, 1996g 10 NA 12.8 7.6 NA 0.08 Fairly satisfied, 1996g 55.1 NA 53.2 40.5 NA 15.5 Note. US=United States; UK=United Kingdom; LEB=life expectancy at birth; LE=life expectancy; NA=not available. aSource. Organization for Economic Cooperation and Development.6(p27) b1998. c1997. dDefined as life expectancy with the ability “to perform those activities essential for everyday life without significant help.”6(p27,31) eSource. Organization for Economic Cooperation and Development.6(p30) fSource. Harvard–Louis Harris Interactive 1990 Ten-Nation Survey, cited by Blendon et al.7 gSource. Eurobarometer Survey, 1996, cited in Mossialos.8 consists of different plans for dif- Unlike Medicare, however, of coverage. Following its original lowing an agrarian metaphor—as ferent occupational groups, they French NHI coverage increases passage in 1928, the NHI pro- a set of 3 sprouting branches: all operate within a common as individual costs rise, there are gram covered salaried workers in (1) pensions, (2) family allow- statutory framework.35–37 Health no deductibles, and pharmaceu- industry and commerce whose ances, and (3) health insurance insurance is compulsory; no one tical benefits are extensive. In wages were under a low ceil- and workplace accident cov- may opt out. Health insurance contrast to Medicaid, French ing.38,39 In 1945, NHI was ex- erage.20 The first 2 are managed funds are not permitted to com- NHI carries no stigma and pro- tended to all industrial and com- by a single national fund, while pete by lowering health insur- vides better access. In summary, mercial workers and their the third is run by 3 main NHI ance premiums or attempting to French NHI is more generous families, irrespective of wage lev- funds: those for salaried workers micromanage health care. For than what a “Medicare for all” els. The extension of coverage (Caisse Nationale d’Assurance ambulatory care, all health in- system would be like in the took the rest of the century to Maladie des Travailleurs Salariés, surance plans operate on the United States, and it shares a complete. In 1961, farmers and or CNAMTS), for farmers and traditional indemnity model— range of characteristics with agricultural workers were cov- agricultural workers (Mutualité reimbursement for services ren- which Americans are well ac- ered; in 1966, independent pro- Sociale Agricole, or MSA), and dered. For inpatient hospital ser- quainted—fee-for-service prac- fessionals were brought into the for the independent professions vices, there are budgetary allo- tice, a public–private mix in the system; in 1974, another law (Caisse Nationale d’Assurance cations as well as per diem financing and organization of proclaimed that NHI should be Maladie des Professions Indépen- reimbursements. The French in- health care services, cost shar- universal. Not until January dentes, or CANAM). In addition, demnity model allows for direct ing, and supplementary private 2000 was comprehensive first- there are 11 smaller funds for payment by patients to physi- insurance. dollar health insurance coverage workers in specific occupations cians, coinsurance, and balance granted to the remaining unin- and their dependents, all of billing by roughly one third of NATIONAL HEALTH sured population on the basis of whom defend their “rightfully physicians. INSURANCE residence in France.40 earned” entitlements.41 Like Medicare in the United NHI forms an integral part of The CNAMTS covers 84% of States, French NHI provides a NHI evolved, in stages, in re- France’s social security system, legal residents in France, which great degree of patient choice.
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