The French Health care system:
Liberal Universalism
Monika STEFFEN
CNRS/Pacte - Institute of Political Studies,
Grenoble University / France
Seminar: “Health and Social Protection
Policies”
Oswald Cruz Foundation, National School of Public Health
“Sérgio Arouca”, Rio de Janeiro, 11-12 March 2009
Classifying and comparing
healthcare systems
• Three theoretical models:
– NHS, SHI, Private systems
• Main opposition : NHS / Private systems
– Contrasting situation for regulation and choice
• In reality, most systems are mixed
– Mix is growing with ongoing reforms
• Hybridization: learning, adapting to global
constraints, creating sustainability
Models versus Hybridization?
• If all systems are mixed, what use for models?
Are all systems « national » ?
• The French healthcare system: little known,
complex. How to classify? An exception ?
• Comparative traditions: WFS / Healthcare
systems
– Universal / private; SHI / state run
• Models are analytical tools: helping to describe
systems and reform trajectories.
Main arguments
• The « same » institution (SHI) is run by
different actors, having a different history,
different self-understanding and values.
• In the HC sector, professionals/doctors are
crucial actors for reform implementation.
• The medical profession has to negotiate its
place, role and power within the social
security system in a different set of policy
actors in each country.
PLAN of paper
• History of the main actors
• Reforms in access, financing, regulation of
consumption
• Regulation in the ambulatory care sector:
no progress, policy crises
• Regulation in the hospital sector:
slow but real progress
A generous healthcare system
Expenditure
in
% of GNP
Expenditure
per capita
in Euros
Employed
Nbr Doctors
% of total
for
Employment 1,000 inhab
2006
11
3,150
2000
10
2,390
1990
8.4
1,485
7.8 (93)
3.1
1980
7
566
6.3 (82)
1.0
8.0 (05)
3.4
3.4
History and its lasting impact
• Medical profession: « liberal » identity, four
principals (fees, site, prescription, secret)
• Mutual benefit funds: doctors’ ally. Lasting
role as supplementary insurers.
• Health insurance: 1930,1945: late, weak.
1967: class struggle, state control.
• Political regulation: consensus for inflation
(opinion, elections, doctors, employment).
• Finance ministry remains isolated.
Financing
• Public/private share unchanged 1995-2006
despite lower reimbursement for medicines.
• +78 % public, -9% out of pocket, 13 %
complementary insurance, mainly non-forprofit.
• Very small market fringe for for-profit HI
• Slight growth of employer-sponsored
supplementary HI (careful privatization).
Reforms for extending financing
• 1991: first introduction of « general social
contribution », then several extensions.
• 1996: GSC replaces HI-contribution (but
employer part remains on salaries).
• 1996: Reimbursement of Social Deficit: 0.5
% for 13 years, 2004 «indefinite time».
• 2004: further increase of GSC: 6.2 to 6.4 for
work income, 7.5 to 8.2% capital income.
Reforms extending universal
access
• 1883 «Medical assistance » at local level.
• 1988 Minimum Income with free HI affil.
• 2000 Unifying the schemes and free
affiliation to a complementary HI (5 mill).
• 2004 Correcting threshold effects.
• 2007 Increasing the latter from 15 - 20 %.
• Medical assistance for illegal migrants.
Weak attempts to reduce choice
• 2001: modulate reimbursement for 850
medicines with little or no effect: 8 years.
• 2003: Chadelat report: restrict basket, only
now attempts for «100% long term illness».
• 2004: Voluntary enrollment with GP for
gate-keeping, penalty 20% less reimbursed.
• 2004: High Health Authority, for basket
restriction, politically critical enterprise.
Weak regulation
• 1996: Parliament votes the annual growth
rate ONDAM, overspending up to +100%.
• Main raisons:
– 100% long term illness regime,
– private doctors do not respect medical
guidelines. Policy deadlock since 1993,
– Difficult redistribution of hospital capacities.
• Hospital management has improved, in line
with international practice.
Characteristics of French system
• 1- Split in regulation between ambulatory
care system (liberal doctors, SHI) and
hospital sector (state managed via regional
agencies).
• 2 - Weak regulation capacity: Bismarckian
SHI without social partners to manage it,
and central government limited by electoral
risks.
3 - A model combining universalism and
liberalism: it is historically grounded, and
growing with the reforms:
4 - … instead of cost containment, new
finance is provided and deficits are put on
future generations.
5 - Liberal universalism is a sustainable
model for the future:
6 - …the public trust towards the mutual
funds allows to absorb the growing cap
between HI-income and expenditure.
7 - Muddling through will continue... ...
THANK YOU
for your attention