A Lesson from France on Coooperatives?

Today, in Washington, DC, representatives of the Mutualité Francaise are meeting with key health committee staff in Congress and with the White House’s Office of Health Reform to help them understand how non-profit mutual aid associations in France serve to provide complementary health insurance for 38 million people through a system of 823 different aid organizations. Mutualité Francaise is the organizing body that coordinates the work of those many groups, lobbies on their behalf and provides technical and regulatory services. The mutual (mutuelles) are more than just a private adjunct to the central social security structure. They also operate clinics, dentists’ offices, optician offices and clinics, laboratories and pharmacies. They also provide support to health professional groups. Their power and place in the French health system is a product of the history of labor relations and the power of independent organizations in the French political structure.

The mutuelles provide what is generally classed as “assurance maladie complementaire” or complementary health insurance over and above the social security coverage offered by the major insurance organizations, the Caisses d’assurance maladie. The complementary sector, represented by the Union nationale des organisms d’assurance maladie complémentaire (UNOCAM) involves both private health insurance companies and the larger mutuelle component which provides 60% of the complementary coverage. There are lessons to be learned about how not-for-profit organizations can work in a mixed health insurance structure in the US but they will be complicated by the very complex history of the mutuelle movement.

The mutual insurance companies in France, “mutuelles de santé” are a fairly unique institution in that country. They grew up as an extension of working men’s clubs, as mutual aid societies, more centered on salaried employees than mass-labor. Their emergence and role in health reform is chronicled in Paul Dutton’s book, Differential Diagnosis: A Comparative History of Health Care Problems and Solutions in the United States and France. Dutton describes how, in 1930, when a mandatory health insurance law was passed, the mutuelles were given a specific and powerful role in running those entities. The mutuelles included collaborative groups of physicians, especially surgeons but they were not aligned closely with the trade and professional associations of physicians. At roughly the same time in the US non-profit health insurance organizations like Blue Cross and Blue Shield and cooperative health systems were emerging and there was a real opportunity for insurance legislation to be written to favor these groups. That did not happen and the private firms were left with the opportunity to compete and eventually dominate the market.

The mutuelle movement strongly promotes its non-profit values contrasting themselves with private insurance. They bill themselves as a democratic movement and a union of people, not capital, administered by the members themselves. They base their coverage decisions on the experience of the entire group, not on individual risks….

"Les mutuelles mettent en oeuvre la solidarité entre leurs membres. Elles ne procèdent pas à une sélection personnalisée des risques à l'adhésion et elles n'instituent pas des conditions tarifaires personnalisées. La Mutualité développe une action d'intérêt général en favorisant l'accès aux soins de tous et l'amélioration de la protection de l'adhérent." (Analyse comparative du Code de la Mutualité et du Code des assurances. www.mutualite.fr)