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Case Study: France

The French health care system has been lauded in the U.S. for providing patients choice in doctors and comprehensive coverage. However, the system has proven over-ambitious and has faced sky-high rocketing costs, massive debt and questions about its sustainability.

Overview

A private-public hybrid

France essentially has a two-part system with publicly mandated base coverage augmented by individually-purchased supplemental coverage. Everyone in France has “sécurité sociale,” basic coverage provided via the government.

France implements an employer-based system in which employers contribute a large portion of the health care costs. Employees pay 0.75 percent payroll tax and a 7.5 percent General Social Contribution, the majority of which is earmarked for the health system.¹ To supplement the government coverage, most French residents have additional coverage through not-for-profit, employment-based mutual associations called “mutuelles.” ²

Reimbursement System

Unlike most European systems, the French typically pay directly for their medical treatment and are reimbursed a percentage which is set by the government. Generally, sécurité sociale pays consumers back around 75-80 percent of the costs of visits to the doctor. This leaves co-payments that range from approximately 10 to 30 percent of total cost, depending on the service.³ The mutuelles reimburse much of the remaining costs.

French health care also uses a reimbursement system for the cost of medication. The reimbursement for drugs varies greatly depending on the type and the condition treated, including:

• No reimbursement for so-called “comfort” drugs or medications not specifically prescribed by doctors
• 35 percent reimbursement for drugs used for short-term conditions that are “neither major nor…important” ⁴
• 65 percent reimbursement for most other drugs
• 100 percent reimbursement for very costly medications or those that treat chronic conditions ⁵

The French system is generally praised in the U.S. because it preserves patient choice in their doctors. Both sécurité sociale and mutuelles cover care in both public and private medical facilities. Almost all doctors participate in sécurité sociale and coverage is generally wide-ranging and comprehensive.

Cost of the French System

High costs are the greatest problem within the French health care system

• In total, the French pay more for their health care than people in most other countries
  • Patients pay around 10 percent of household income, before taking into account additional costs for mutuelle coverage, co-payment costs, and costs of treatments that are not covered.
• France’s system is expensive in comparison to its neighbors
  • France spent 11.1 percent of its GDP on health care in 2005— the third highest percentage in the world and more than every other country in Europe except Switzerland. ⁶
• Despite the large amounts of money put into the health system, the system carries billions of dollars in debt
  • Sécurité sociale will be an estimated 8.9 billion euros in debt in 2008, and 11.8 billion in debt by 2011. ⁷
• Doctors in private practice can charge fees above the amount reimbursed by the government, forcing patients to pay the difference out of pocket.
  • In some communities, a majority of physicians charge these higher fees. This is evident in Paris, where 80 percent of doctors charge above the reimbursement level.

Low Doctor’s Salaries

One reason doctors charge more than the state reimbursable rate is because they are paid far less than their counterparts in other countries. French physicians’ salaries average only around €40,000 ($55,000) a year, little more than a third of what the average American primary care doctor receives. While medical school tuition is free in France, the number of students accepted to continue after the first year is highly restricted.⁸

Quality of Care

• In some regions, France has a shortage of advanced medical technologies, including CT scanners and MRI machines. This has resulting in long wait times for important diagnoses for some patients.
• Financial incentives strongly encourage patients to seek care through “gatekeeper” doctors.
• Some patients ‘diagnosis shop,’ consulting many different doctors and forcing the system to pay out more. ⁹

Underinsurance

Underinsurance is also a problem in the French system as mutuelle plans vary in price and comprehensiveness. Not all citizenscan afford supplementary coverage. About eight percent of the population makes too much to receive free sécurité sociale coverage, but not enough to pay for sufficient coverage out-of-pocket. These people can face obstacles to access needed treatments.¹⁰

Burden on Employers

The French system faces challenges due to the link between health coverage and employment. Hiring is sometimes impeded because of the costs to the employer. ¹¹ However, the French do not lose their coverage if they change jobs or become unemployed.

Reforms are considered necessary in France and the current government has made reform a priority. It is clear that despite the praise of many outsiders, the French system is far from a perfect model. The system struggles constantly with funding and is plagued by debt. Additionally, cultural variables could make it an unpopular choice for the U.S., where citizens are less likely to agree to put universal access ahead of the quality of the treatment.

1. ¹ David G. Green, Ben Irvine and Ben Cackett, “Health Care in France,” Civitas, (2005), http://www.civitas.org.uk/pubs/bb2France.php.
2. ² Article L111-1, alinéa 1 du code de la mutualité, http://www.legifrance.gouv.fr/affichCode.do;jsessionid=F828D2E8143C1579441CEF6481BB4DC0.tpdjo03v_3?idSectionTA=LEGISCTA000006142671&cidTexte=LEGITEXT000006074067&dateTexte=20080709.
3. ³ Tanner.
4. ⁴ Green, Irvine and Cackett.
5. ⁵ http://www.doctissimo.fr/html/medicaments/articles/sa_6347_medicaments_remboursement.htm
6. ⁶ OECD Health Data 2007, http://stats.oecd.org/wbos/Index.aspx?DatasetCode=HEALTH
7. ⁷ “Cnam: Bachelot veut 4 milliard d’économie,” Nouvel Observateur, 8 July 2008; “Le déficit de la Sécurité sociale prévu à 8,9 milliards d’euros en 2008,” La Tribune, 18 June 2008, ; François Wenz-Dumas.
8. ⁸ Ibid.
9. ⁹ Tanner.
10. ¹⁰ David Alves da Silva, « La réforme des systèmes de santé », Revue du MAUSS permanente, 14 mars 2008 [en ligne]. http://www.journaldumauss.net/spip.php?article303.
11. ¹¹ Paul V. Dutton, “France’s model health care system,” Boston Globe, 11 August 2007, http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/08/11/frances_model_healthcare_system/.