1. French Health Care System
1.1. A System Under Pressure
The system of health care in France is known as l'assurance maladie, or the Sécu, an abbreviation of sécurité-sociale, although the latter term is often also used to refer more generally to the system of social security in France.
It is often rightly praised for the quality of the treatment and the level accessibility it offers to patients.
France certainly spends a lot of money on health, around 10% of gross national income, one of the highest rates in the world.
Perhaps as a result of this expenditure the French enjoy a life expectancy only exceeded by that of the Japanese!
Nevertheless, the system is under severe financial pressure, there is a growing shortage of suitable staff in many regions, and a higher proportion of the running costs are having to be picked up by patients.
At an institutional level the organisation and financing of the system is complex and is often characterised by high levels of tension between the various parts of the system.
Most health professionals who work outside of hospitals are self-employed and depend for their income on fee paying patients whose costs are reimbursed by the social security and voluntary health insurance systems.
Patients, in turn, have been allowed to have unrestricted access to doctors and specialists with the result that no-one in the health system has had any particular incentive to keep down costs.
Over the past few years the government has introduced a series of reforms, the whole purpose of which is to increase efficiency and drive down costs. These reforms are on-going.
Social security health contributions have been increased, as have fees for medical consultations, whilst reimbursement levels have been reduced.
At an administrative level everyone is now required to register with a doctor to obtain the full level of reimbursement, medical records for patients are to be introduced, and there have been some reforms to the institutional structure.
Continuing concern about rising costs has resulted in stronger controls by government limiting the freedom of professionals and patients and controls on the prices of drugs.
To anyone from outside of France some of these reforms may appear logical and long overdue, but there is widespread concern in France about their impact.
Many health professionals consider the changes are too bureaucratic, and there are many commentators who consider that the costs of health care are going to increasingly fall upon poorer members of the community and those who are ill.
In short, like most other developed nations, France can no longer afford its health service.
1.2. Structure of Health System
Health care in France is funded by a dual system of health insurance comprising:
- A State controlled health insurance social security system, called l’assurance maladie and;
- A separate voluntary health insurance system called assurance complémentaire provided through mutual organisations and private insurers.
Whilst the social security system picks up most of your health costs, you will need to take out voluntary health insurance to cover those medical costs that will not be picked up by the State, although it is not compulsory to do so.
We will review voluntary ('top-up') insurance in later pages but, for now, we just consider the State funded part of the system.
Accordingly, in order to obtain access to the health service in France, and obtain reimbursement of costs, you need to be registered with l’assurance maladie.
Historically, l’assurance maladie comprised a number of private or mutual insurance bodies who collected insurance premiums from their clients, which were then used to pay for the costs of health care.
They developed after the Second World War as a series of mutual schemes between employers and employees, and the present arrangements still bear the hallmarks of this approach.
Although the insurance funds continue to be ostensibly ‘private’ organisations they now operate under the supervision of the government, who have ultimate financial responsibility.
Accordingly, the funds are now effectively a branch of the state social security system.
The main health insurance fund is a General Fund called the Régime Général that covers about 85% of the population working in industry and commerce, as well as the unemployed and those retired and not affiliated to another fund.
Within the Régime Général the Protection Universelle Maladie (PUMA) guarantees permanent health cover for all those who are legally entitled to reside in France, whether in work or inactive.
At a local level the General Fund is administered by a health authority, called the Caisse Primaire d’Assurance Maladie (CPAM).
In the past, if you were planning to run your own business in France there is a separate State controlled insurance scheme for the self-employed called Régime Social des Indépendants (RSI).
Since 2018 the RSI is in the process of being abolished, so that all those affiliated will be transferred to their local CPAM.
There are then separate health insurance funds for agricultural workers and other smaller schemes for specialist professions, e.g. civil servants, railway workers, doctors.
Next: Getting Health Cover
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