Quick Facts: 

• Population (2009): 64,057,79
• GDP per capita (2008): $32,700
• Life Expectancy (years): M 78, F 85
• Infant Mortality: 3.3 deaths/1,000 births
• Physicians per 10,000 people (2000-2009): 37
• Government health expenditures as percent of total government expenditures (2007): 16.6%
• Almost everyone covered by public universal insurance (Securite Sociale) paid for by government, and covers most services including hospital, outpatient, prescription drugs, nursing home care
• For many conditions, including cancers, diabetes, and chronic illness, there is 100% coverage of health care costs
• 92% of people purchase additional private insurance, which helps cover co-payments and services not covered by Securite Sociale
• Supplemental insurance paid for by government for low income, according to means.
• Choice of physician or specialist is up to the user, who pays cost up front and is then reimbursed by the government.
• A person’s Securite Sociale card contains his or her electronic medical record

Sources: CIA World Fact Book  and WHO World Health Statistics 2010; more statistics can be found at http://www.globalhealthfacts.org

Background Brief

The French health care system has been lauded by many for being marked by a self-regulating market with widespread diversity in which all consumers have health coverage and can choose when to go and whom to see for medical care. However, some critics have observed that the historical lack of gatekeeping protocols have helped drive the system into economic deficit. In 2005, health minister Philippe Douste-Blazy introduced a series of health reforms designed to reduce the deficit. Economic situation notwithstanding, the World Health Organization ranked the French health care system No. 1 in 2000, on measures of overall population health, health inequalities within the population, health system responsiveness within various sectors of the population and distribution of financial burden. [1]

Access:
Almost all residents are covered by two methods: they have public, universal insurance, which is financed by the government; and more than 92% have private, supplemental insurance, roughly half of which is funded by employers, while the other half is paid for individually. The federal government funds supplementary insurance for those who cannot afford it. The mandatory public insurance, called Sécurité Sociale, covers most services, ranging from hospital care, outpatient services, prescription drugs (including homeopathic products), nursing home benefits and more. The complementary insurance generally refunds any co-payments associated with the basic insurance, and enables the basic insurance to fully cover some services that otherwise would be only partially covered, such as dental and optical care.

The government automatically enrolls all residents into the basic public health insurance system based on occupational status. The 0.4% of the population not covered by Sécurité Sociale, such as the unemployed,is mandated to carry universal health coverage (couverture maladie universelle, or CMU). It is available to all those living in France for three months or longer, and provides coverage under the basic public health insurance scheme, and free complementary private coverage.

There are approximately 30 conditions – including cancer, diabetes and other chronic conditions – for which a citizen may receive 100% coverage of health care. This includes all pharmaceuticals, including experimental drugs.

Most cost-sharing in France is in the form of coinsurance fees fixed by the health insurance funds, and includes 20% coinsurance for hospital services, plus a daily copayment limit; and 30% coinsurance for outpatient physician services, plus a nominal copayment per consultation, limited to €50 per year. [2] Overall, household out-of-pocket payments as a proportion of total national health care expenditures have declined over time, from 30.3% in 1960 to 6.9% in 2005. [3]

Public and private supplementary health insurance funds, through which almost all French citizens receive care, are not allowed to compete by lowering health insurance premiums – in general, French citizens and non-citizens contribute according to their means; also, the French believe that competition could lead to privatization, which would be an unacceptable departure from their current philosophy of solidarity.

Coverage and reimbursement details, in turn, are negotiated between the health insurance funds and unions representing providers. [4] Also, until 2005 there were no gatekeepers to regulate access to specialists and hospitals. [5] And so, due to high utilization of health care services, and health care spending outpacing economic growth, the French have a large budget deficit, which is the subject of much debate and target of health reform legislation. The most recent law to address health reform is known as the Douste-Blazy law, which addresses several facets of the health care system, including – perhaps most controversially – financial incentives to patients over the age of 16 who choose a primary care physician, through whom the patients agree to go for referrals to specialists. [6] Regardless of financial challenges, France’s unique and complex mixture of public and private financing for health care has prompted some American health reform advocates to look to the French system for guidance. [7]

Financing
The federal government sets annual health care spending goals and contracts with health insurance funds to manage the system, but health care providers and facilities have considerable autonomy in daily spending and decision-making. Every year, the French parliament passes a law that creates the annual prospective global budget for the public health expenditures. This budget funds the Sécurité Sociale and CMU and is financed through national income taxes and the General Social Tax – a supplementary income tax (7.5%) introduced in 1991 to help offset health care costs; 5.25% of which helps pay for the health care system. [8] In 2004, employer payroll taxes funded about half of national health insurance expenditures; the General Social Tax contributed about 36% and the remainder of funding came from special taxes levied on tobacco and alcohol and to the pharmaceutical industry.

In terms of total health spending, public expenditures funded 79% of the total health spending in 2007. [9] The remaining health spending is divided between complementary health insurance (13%) and out-of-pocket payments for medical services, products, and pharmaceuticals (7%). [10] Complementary health insurance is financed by employer and individual payments, split roughly evenly between the two sources.

The total health expenditure of the nation was estimated at 11% of GDP in 2005, more than any other member state of the European Union except for Switzerland. [11] Financial sustainability has been a major issue for the French health care system for decades as large deficits plague the system. Recently, though, the deficit has fallen, from €10-12 billion per year in 2004 to an expected €6 billion in 2007.

This may be due to a series of health reforms that have taken place in recent years to help contain costs, including a reduction in the number of hospital beds, limits on the number of reimbursable drugs and new co-payments for prescription drugs, protocols for the management of chronic illness and the introduction of a voluntary gatekeeping system in primary care. [12]

Service Delivery
In France there are three types of medical institutions: public hospitals, private not-for-profit hospitals, and private for-profit hospitals and clinics. Public and private not-for-profit hospitals tend to offer a wide-range of services, while private for-profit hospitals and clinics focus mainly on minor surgical procedures. Most hospital beds (65%) are in public hospitals; the remainder are split between private not-for-profit (15% of inpatient beds) or private for-profit (20% of inpatient beds). [13] The supply of hospitals and medical technologies is sufficient to avoid the issue of wait times that is common in other nations. In rural areas, however, there are fewer providers and hospitals. A recent survey showed that most French are satisfied with the proximity of available health services, although slightly more than a third of those living in rural areas stated that specialist services were not located close enough. [14]

Doctors and other health care professionals are mostly self-employed and paid on a fee-for-service basis. Patients have complete control over which doctor they choose to see, and if they are willing to accept lower levels of compensation, patients can self-refer to specialists and secondary care providers. Upon receiving care, patients visiting physicians and dentists pay full price and are later reimbursed for costs by the public health insurance and complementary insurance. For other services, such as pharmaceutical costs, they are reimbursed on the spot. Patients are exempted from paying if they receive public assistance (CMU) or if they visit a procedure-oriented specialist.

In the French system, patients carry Sécurité Sociale cards containing microchips storing their comprehensive medical information, allowing physicians immediate access to a patient’s record. The card also serves as a mechanism through which patients are almost immediately reimbursed for their medical care: when it is scanned at a health care facility, electronic funds are quickly deposited into the patient’s bank account as reimbursement for the appropriate portion of any fees associated with the visit. [15]

BACK TO TOP

Resources

Bellanger, M.M. and P.R. Mossé (2005). The Search for the Holy Grail: Combining Decentralized Planning and Contracting Mechanisms in the French Health Care System. Health Economics. 14: S119-S132.
This article describes the structure of the French health system, and summarizes changes that have occurred in terms of funding and coverage over the last few decades. It focuses on financing, access and outcomes.

Buchmueller, T. C. and A. Couffinhal. (March 2004). Private Health Insurance in France. Organisation for Economic Cooperation and Development.
This working paper takes a closer look at the French health insurance system and analyzes the market for private health insurance.

Davis, K. (October 2008). Slowing the Growth of Health Care Costs--Learning from International Experience. The New England Journal of Medicine, 359.17.
In this article, Karen Davis discusses how several countries including France drive health care costs down by negotiating prices with doctors and pharmaceutical companies.

Dutton, P.V. (2007). Differential Diagnoses: A Comparative History of Health Care Problems and Solutions.
Dutton compares the French and American healthcare systems, examining how the French have reconciled the notions of individual liberty with social equality in order to create a health care system the WHO has rated the best in the world.

Embassy of France. (2005). The French Healthcare System. 2005.
This article from the United States Embassy of France gives a brief overview of the organization and individuals involved in the health care system. It includes updates on a variety of health policy developments, including the Act of 13 August 2004 on health insurance reform, the Act of 9 August 2004 on public health policy and the 2012 Hospital Plan.

Grosse-Tebbe, S., and J. Figueras. (2004). Snapshots of Health Systems. France. WHO on behalf of the European Observatory on Health Systems and Policies.
This resource contains profiles of European health systems. The snapshot of France provides a brief overview of the organization and financing of the health care system, with an eye toward developments and issues the system faces in the future.

National Public Radio. Health Care for All.
NPR provides an in-depth look at the health care system in France, Germany, the Great Britain, the Netherlands, and Switzerland. It provides segments on different aspects of the health care systems, and also includes an international comparison of these countries. One story focuses on the French system and maternity care.

Poullier, J.P. and S. Sandier. (2000). France. Journal of Health Politics, Policy & Law, 25.5: 899-905.
This article discusses changes made in the financing and delivery system of health care in France from 1996 -2000. Particular focus is given to the mix of government and the marketplace in the French health care system.

Rodwin, V.G., ed. (2006). Universal Health Insurance in France: How Sustainable? The Office of Health and Social Affairs, Embassy of France, Washington, DC.
This series of essays both consider French health reform and describe the organization, financing and management of health care in France. Essays were culled with an eye on informing U.S. policymakers of France’s health system’s strengths, weaknesses and reform policies. The essay collection also contains an English-language bibliography on the French health care system.

Rodwin, V.G. and C. Le Pen. (November 2005). Health Care Reform in France—The Birth of State-Led Managed Care. The New England Journal of Medicine, 351.22:2259-2262.
This article explains the challenge for the French government of achieving their desired balance between a cost-effective national health insurance system and sufficient provision of choices to individuals.

Rodwin, V. G. (January 2003). The Health System Under French National Health Insurance: Lessons for Health Reform in the United States. American Journal of Public Health, 93.1: 31-37.
The author argues that the United States, as it attempts to reform its own health system, could learn from the French health system. Even though the French are reforming their health system, it still functions well as an important model for the United States. Rodwin provides five propositions to spark debate.

Sandier, S., V. Paris, and D. Polton. (2004). Health Care Systems in Transition: France. WHO Regional Office for Europe on behalf of the European Observatory of Health Systems and Policies.
Health Care Systems in Transition (HiT) profiles provide an in-depth description of various countries’ health care systems, and of current reform initiatives. This HiT, on France’s health care system, provides a comprehensive and analytical report of the system’s organization, financing and delivery mechanisms, and provides an historical context through which to better understand the system’s structure today.

WHO Regional Office for Europe. (June 2006). Highlights on Health, France 2004.This article provides basic information about the organization, financing, and development of the health system in France.

BACK TO TOP