As a follow up on my recent post over at dKos with personal news about the health of my son, it might be interesting to provide some information on how the French health care system works.
The health care system is part of the larger “Sécurité Sociale”, which in France also includes pensions, invalidity support, and unemployment benefits and several other smaller benefits. But we use the term “Secu” to talk about the healthcare system, and that’s what I will use below. I’ll also describe the main cover provided to people who are salaried with an employer. There are semi-separate systems for the self-employed, farmers, and other categories, with the main difference being on the level of taxes to pay for these and the way they are levied. I won’t go in that level of detail here.
Health care is provided by a combination of public sector (hospitals) and private sector actors (clinics, doctors, pharmacists). You are free to choose where you will be cared for and by whom, and you pay for it yourself in full, unless you have specific cover (see below). The main rule is that the public system reimburses you up to an agreed amount for each medical act. If you go to a doctor that uses the State tariffs, then you will end up paying nothing; if you go to a more expensive doctor, you have to pay the difference.
We’ve had our share of financial crises with the system, as expenses are growing faster than the economy, and there have been regular “patches” to the system, the main ones being an increase in the taxes allocated to it (in the main fund, employers today pay 13.8% and employees 0.75% of the gross salary into the pot) and a reduction of the portion of the agreed tariff which is actually reimbursed to you (currently, it is 65% for most basic expenses, like doctor visits and medecine).
A second layer then kicks in, which we call “mutuelles”; in essence these are additional (and optional) medical insurance, provided by the private sector. In most companies, such coverage is provided by the employer as part of the employment package, but even if you don’t, such coverage can be found for something like 100-200 euros per month, depending on the quality of the coverage.
Such coverage usually pays for all or most of the difference between the agreed tariff and the “Secu” reimbursement (which makes you ending up paying nothing, or a small amount, typically 5% of the real cost); it also can provide for higher limits to the reimbursement of a doctor consultation – which allows you to go see more expensive doctors if you wish. For instance, the tariff for a visit to the pediatrician is set at 28 euros – my current mutuelle will reimburse me in full up to 40 euros per visit, so I choose to go to a 50 euro pediatrician that we appreciate and we end up paying 10 euros ourselves. These mutuelles are important as they provide coverage for dental and ophtalmologic (glasses) care, which are very poorly covered by Secu.
All heavy duty or long term care is FULLY covered by Secu, including transportation allowances and, as I wrote, stipends for parents if full time care is required. If you have a mutuelle, Secu will get that mutuelle to pay for a portion of the cost of the treatment/care.
So with both la Sécu and your mutuelle, which cost little, you get a pretty good coverage. Of course, the downside is that there are few limits to demand for health care, and people do not moderate their number of visits to the doctor and their consumption of medication and treatments, and the system is chronically in financial dire straits, which are patched every couple of years by a combination of lower repayments and increased taxes (of course, increase mutuelle payments do not count as taxes, but they come from the same pocket in the end). Various fixes have been tried to limit medical overconsumption, the most recent being the obligation to see a GP before going to a specialist, having a “preferred” MD to treat you, and building an electronic record of your medical files, so that duplicate exams and tests are avoided.
It’s a big topic here, chronically in the news, but there is always a consensus to find solutions; the government usually wants to shift a part of the costs on the population, while the unions try to make the companies pay for it.
The part to be paid by the population has grown so much in the past 20 years (from essentially zero to 35% now) that it had become an issue for the really poor to get access to health care, in view of the cost for them. So a new layer was put in place 5 years ago, the “Couverture Medicale Universelle”, which provides for 100% coverage if you fall below certain revenue levels or if you receive the RMI (Revenu Minimum d’Insertion – a monthly stipend that you receive if you have nothing else, no work, no unemployment benefits, worth about 400 euros per month. Just above 1 million people receive it in France today). The CMU is a sort of equivalent of your Medicaid, but thanks to it pretty much nobody is uncovered, as if you do not qualify for CMU, it means that you already have coverage.
There are regular lobbying efforts by various parties to get a better deal:
- doctors wanting their agreed tariff to be increased in order to increase their revenues (a large majority of doctors actually use that tariff – 20 euros for a basic visit, 23 euros for a specialist -except pediatricians as stated above);
- drug companies wanting (i) a better tariff for their drugs and (ii) a better proportion of the cost reimbursed by Secu (that proportion is lower for “comfort drugs”, the definition of which is done on a case by case basis)
- Emergency room doctors are running chronic protests (they are on strike this week) to get better support, as they are often the only available place for care when doctors are closed at night, during the week-end or during holidays, and they don’t require you to pay upfront; they are often short on staff and see the worst cases like the homeless (they also had to deal on their own with the early days of heat wave two years ago, before emergency plans were kickstarted);
- companies complain about the high level of taxes they have to pay and lobby to switch funding to the population or the insurance companies;
- the insurance companies find the market profitable and are keen to take a bigger role.
The general impression in France is that, while we have a good system, it is in a crisis and new solutions need to be found to preserve it and fund it over the long run. As in any large bureaucracy, there are a number of things that don’t work very well, are wasteful or badly organised, and we love to complain about it. In any case, it is clearly seen by most people as a vital part of what makes the country stick together, an essential element of solidarity and fairness to all in the country.
I am not a specialist of the topic and see it more as a “consumer” than a real expert, and I have certainly over-simplified things. I hope the other few French posters around can correct any blatant errors, and that other European posters can provide some insights in their own systems.
I’ll try to answer your questions to the best of my knowledge.