The US is going through a spirited debate about health reform that is focused mainly on how to finance medical care. France has developed, over time, a social insurance system that covers virtually the entire population for most medical care expense. The comparisons that have been made to the US range from very laudatory (Michael Moore) to critical and negative (Michael Tanner). T. R. Reid’s recently released book, The Health of America” gives praise to the French and other systems, contrasting them with the non-system in the United States. Senator Kent Conrad has recently commented positively about the French system as noted by Ezra Klein. Reactions to praise for government-sponsored health insurance systems have focused on the potential for rationing or the threats to individual freedom. When France is cited as having better health outcomes, critics make use of a controversial statistical analysis that sys that US mortality would equal that of France if deaths from injuries and violence were taken from the numerator..
The French medical care system is supported by the overall Social Security structure, popularly called “Secu” for “Sécurité Sociale”. Health care in France consumes 11.2% of the national income making it one of the most expensive systems in Europe, lagging only behind Switzerland. The overall financing for health care in generally included under a structure called l’assurance maladie, or sickness insurance. This is a social insurance system, often called a Bismark form of financing for health care. Prior to 1945 and the creation of the overall Secu system, mutuelles, or mutual insurance companies provided coverage to employed or self-paying people. They have since developed alongside the national system providing a supplemental private option for French citizens and legal residents.
According to the Ministry of Health report released in September 2009 the overall costs of health care in France in 2008 rose to 215 billion euros or 11% of the GDP; the costs of direct care (consommation de soins et de biens medicaux) accounted for 170.5 billion euros, 8.7% of GDP. The annual growth rates of these two indices, 3.8% and 4.4% were faster than overall GDP growth of 0.7% in 2008 following a 2.1% growth in 2007. The Secu covered 75.%% of the costs of care with complementary insurance covering 13.7% and out of pocket payments, 9.4%. The French government is concerned with the pace of growth of costs but sees the rate as slowing to a plateau after a very rapid rise in 2000-2004. Financing and structural reforms are anticipated to keep cost growth in line with revenues.
The health insurance structure covers 99% of the population through three different schemes: the first includes people employed in commerce and industry and their families (84% of the total), the second covers workers in agriculture and their families (7.2%) and third and smallest covers the self employed (5%)—the remainder covered by the “Couverture Maladie Universelle” CMU. The largest of the insurance organizations is called Caisse Nationale d’Assurance Maladie des Travailleurs Salaries (CNAMTS) and it functions as a combination health insurance company, planning agency, and policy making body; the other two follow suit. The CMU was instituted in 1999 to extend benefits from the statutory system to all French citizens and legal residents, regardless of their employment status. In 2004, coverage was further extended to dependent elderly people through a special fund established for this purpose.
The supplementary plans are like American voluntary, private plans and are purchased by individuals, usually from non-profit “mutuelles” (60%) or from for-profit insurance firms (40%). Typically, this voluntary insurance is meant to cover the portion of medical expenses not covered by the statutory plan or any co-insurance or co-pays associated with care – similar to the “medi-gap” plans in the US for Medicare. In 2000, 43% of those with voluntary coverage subscribed independently, but the rest of the population received coverage from their employer similar to ESI in the United States.
France’s National Health Insurance system is funded by employer payroll taxes (51.1%) and a “general social contribution” (34.6%) levied by the French treasury on all earnings, including investment income. In recent years government anticipated losses in the system and has expanded payroll taxes on employees, instituted special taxes on automobiles, tobacco and alcohol, added a specific tax on the pharmaceutical industry , and shifted funds to provide subsidies to programs or sectors. The budget for the health system remains a problem as expenses outpace revenues.
