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ISBN 0-615-13534-X Universal Health Insurance in France: How Sustainable? is published by The Office of Health and Social Affairs, Embassy of France in Washington, DC and is available on Internet at: http://wagner.nyu.edu/health/universal.pdf and at: http://www.ilcusa.org/_lib/pdf/FrenchHealthCare.pdf. Correspondance should be addressed to: Health Office Embassy of France 4101 Reservoir Road, NW Washington, DC 20007-2182. [email protected] Universal Health Insurance in France How Sustainable? Essays on the French Health Care System Victor G. Rodwin and Contributors Foreword The health care systems in France and the United States face a crisis of unprecedented scope. In the United States, uncontrolled health care infla- tion exacerbates the federal budget deficit, threatens the competitiveness of business and increases the already large number of Americans (some 45 million) without any health insurance. In France, whose health care system has been ranked as No. 1 by WHO in 2000, increasing health care expen- ditures threaten the sustainability of its national health insurance system. Policymakers in France and the U.S. could benefit from an understand- ing of their health systems’ strengths, weaknesses and reform policies. It is for this reason that the Office of Social Affairs, Embassy of France in Washington, supported Professor Victor Rodwin’s initiative to organize a colloquium on the recent health care reforms in France, as well as the publication of this book1. I thank Victor Rodwin for his enthusiasm and for his efforts, over the years, to build bridges between the U.S. and France and to encourage mutual learning on how access to health care and quality may be improved on both sides of the Atlantic. Jacques Drucker, MD - Health Counselor Embassy of France - Washington DC May 20, 2006 1. The colloquium, “What’s New in French Health Care Reform?” was held at New York University (NYU) on November 29, 2004 and co-sponsored by the Ecole Libre des Hautes Etudes, the French-American Foundation, and NYU’s Wagner School. Table of Contents Foreword Introduction 1. The Relevance of French National Health 01 Insurance for the United States Victor G. Rodwin Part I French Health Care Reform– How Will the Health Care System Evolve? 2. Health Care Reform in France– 09 The birth of state-led managed care Victor G. Rodwin and Claude Le Pen 3. France Tries to Save its Ailing 15 National Health Insurance System Paul Clay Sorum 4. New Cleavages in the French Health System: 31 Crisis of the health professions Jean de Kervasdoué 1 Part II Organization, Financing and Management of Health Care in France 5. The Health Care System under French National Health 59 Insurance: Lessons for health reform in the United States Victor G. Rodwin 6. The Changing Health System in France 79 Yukata Imai, Stéphane Jacobzone and Patrick Lenain 7. Historical Background, 129 Organizational Structure and Management Simone Sandier, Valérie Paris and Dominique Polton 8. Health Care under French National Health Insurance: 169 A public-private mix, low prices and high volumes Victor G. Rodwin and Simone Sandier Part III Selected Bibliography in English 201 on the French Health Care System Appendices 213 A. Permissions B. Contributors C. Acronyms 1 Introduction 1. The Relevance of French National Health Insurance for the United States Victor G. Rodwin The French health system has not attracted much attention among U.S. policymakers. One might argue that health policy in the United States is largely home grown and that there is little interest in experience abroad. But such a view does not explain why—in thinking about how to extend coverage to the 45 million Americans who are now uninsured—so many more studies have been published, and so many more policy analysts have invoked the Canadian, British and German health care systems.1 Whether this fact reflects the history of tempestuous love affairs between our nations, the perception by the health policy community that France is irrelevant, or simply a cultural divide reinforced by a language bar- rier, is a matter of speculation. I believe that an important part of the explanation is simply the language barrier and that is why a critical crite- rion for selecting the essays assembled here is their capacity to stimulate 2 interest about French National Health Insurance (NHI) among readers of English, who are typically not proficient in French. In discussing the French health care system, most contributors to this volume would probably share my assumption that there is sufficient similarity among the health systems of wealthy nations to make com- parative analyses and case studies of individual systems worthwhile. All nations, after all, are grappling with the same issues of how to sustain their health care systems while introducing new medical technologies, covering their populations, and keeping their health care providers sat- isfied. Policymakers around the world invoke the “exceptional” nature of their distinctive health care institutions and the pitfalls of “learning from abroad.”2 But this view smacks of ethnocentrism. It supports the status quo, and in that sense, a conservative view of the world.3 A more daring approach, more open to policy innovation and the possibilities of mutual learning, starts with the recognition that health systems—how- ever much they differ—are converging, and investigates what might be learned from differences across nations—good practices as well as inter- esting failures.4 It is in this spirit that studies on learning from health systems abroad are conducted.5 But why France? The French health system stands out in contrast to most other Euro- pean health systems in its stronger resistance to the most recent wave of reform efforts that have sought to introduce a dose of competition and market forces within a social context that maintains its commitment to national (although not European) solidarity.6 In France, American nostrums of unleashing market forces under the banner of “consumer- directed health care,” and selective contracting by private health insur- ers, have gained little ground. But that should not lead one to conclude that the French health care system is irrelevant to the United States. The organization and financing of health care, in France, resembles, in many respects, that of the United States—more so, in fact, than do Britain’s National Health Service or Canadian and German NHI. The French reliance on a public-private mix that includes a significant proprietary 2 hospital sector, private fee-for-service medical practice, and enormous patient choice among a pluralistic organization of health care providers makes French NHI a model for what Senator Ted Kennedy and Con- gressman Pete Stark have called “Medicare for all.” Moreover, the fact that French NHI includes extensive pharmaceutical benefits, makes France more attractive than Canada as a possible direction for health care reform in the U.S. Of course, as in Canada, Britain and other European nations, the role of government is different in France than in the U.S.7 Also, a unitary cen- tralized state has different implications for health care management than a federal decentralized system. Despite this notable difference, however, it can still be illuminating to study how the French health care system has evolved to the point where the entire population is now covered under NHI while maintaining the freedom to navigate across a vast range of health service providers. The big policy question for the future is whether the system is sustainable. Indeed, that is the question that unites the essays in this volume. Since the initial choice of papers for this book, two recent articles ar- ticles, in English, were published on the French health care system. The first by Martine Bellanger and Philippe Mossé suggests that there are em- bryonic signs of an emerging decentralization around the possibilities of greater integration through managed care contracting mechanisms that have the potential to increase consumer involvement and improve per- formance.8 Another article by Lise Rochaix and David Wilsford, argues that big reforms in France are unlikely and that the health care system will remain organized very much as it is today.9 True enough, incremen- tal change appears most likely in all health systems. As new technologies appear and more specialty services are diffused, patients are likely to pay more for their health care. This trend is often applauded as an emerging element of “consumer driven care” by some policy analysts in the United States.10 In France, the same trend is occurring in a more disguised form while, on the surface, everyone has access to quality health services. 4 The essays in this volume attempt to understand—in more depth— how French policymakers are struggling to sustain universal coverage while delivering high quality services to all. They were written as separate articles, working papers or book chapters, over the period 1993-2005, and with the exception of Jean de Kervasdoué’s essay, were previously published in English (Appendix A).11 They are assembled here to pro- vide American policymakers, policy analysts and all those concerned with issues of improving access to health care, a balanced view of how the French are attempting to sustain universal coverage under NHI, what current reform efforts seek to achieve, how the health system has evolved and is currently organized, what are its salient character- istics and what lessons might be derived for health care reform in the United States. In Part I of this book, the essays focus on health care reform, in France, and speculate on how the system is likely to evolve. Opinions range from raising the policy dilemmas posed by state-led managed care (Claude Le Pen and I in Ch.

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