A Brief History…

Since 1958, France has been ruled by The Fifth Republic, a democracy with a strong President. It was essentially designed to suit President De Gaulle when he assumed office to resolve the Algerian Crisis. This left France with a very centralized government, a “unitary system of government,” without the states we have or the provinces of the Ancien Regime that ruled France before the Revolution. The Legislature is bicameral with a National Assembly of 577 Deputies directly elected, and a Senate of 321 members indirectly elected and with less power. Deputies of the Assembly serve five years and Senators serve nine years.

Since 1986, the health care system, Securite Sociale, has been decentralized to 22 regions, each with an elected local advisory council. Policy comes from Paris but there is considerable local control. France also has 96 Departments with elected councils, which select a mayor with some public health responsibility.

Hospitals are both public funded, two thirds of them, and private, about half nonprofit but some for-profit. Everyone who is employed in France must join the Securite Sociale and must contribute to the system which has four branches; sickness and maternity, death benefits, invalidity insurance (disability), work accidents, old age and family. It is interesting that Britain, with its unitary NHS, also has a separate workers compensation health system like that in the US. The unions were unwilling to give up this fiefdom when the NHS was founded. We can expect similar resistance from unions to reforms that involved union health plans. France has successfully integrated them.

The entire system is called Natonal Health Insurance, or NHI. The largest system, covering 80% of the population, is Caisse Nationale d’Assurance Maladie des Travailleurs Salaries (CNAMTS), which includes all salaried workers and their families. The system is administered by 16 regional funds and 133 local funds that are self-governing with a board made up of employers and unions. There are 17 other funds covering by occupation such as agricultural workers, civil servants, medical doctors and students. A registration card is issued to each member and is called carte vitale with a registration number. More recently, these cards are embedded with information about coverage, such as the co-insurance, and are read by a card reader in the doctor’s office. There are criteria for membership, including hours worked or contributions made.

Since a 1996 Reform, the parliament has set a budget and the Health Minister chairs a High Committee of Public Health, which sets policy. There is a National Health Conference and Conferences Regionales de Sante, which set local objectives. The 22 regional bureaux are called DRASS, a French acronym, and monitor the regional budgets and hospital construction. We have something similar called Health Planning Agencies that used to issue “Certificate of Need” for new CAT scanners and the like.

French residents register at the local office of CNAMTS, called CPAM or secu of CNAMTS. The secu is responsible for benefits and claims. The regional offices are called Caisses Regionale d’Assurance Maladie, or CRAM, which deal with occupational injuries and social programs. Another agency called Unions Regionales des Caisses d’Assurances Maladie or URCAM, deal with social insurance administration. In 1999, France spent 9.4 % or GDP on health care, high for Europe but well below our own expenditures. These Caisses are actually non-profit agencies that are not part of government but are funded by the payroll tax. They are governed by boards including employers, unions and one-third doctors.

A new (2000) social security tax (Contribution Social Generalisee  –  CSG) was introduced to relieve some of the burden on employment taxes. Supplementary insurance (analagous to our Medi-Gap policies) is provided by three types of organizations. Provident societies (like fraternal organizations), mutual funds (which provided all health insurance prior to 1945), and commercial insurers. There is a great variety of such plans, some group plans tied to professions for example. They provide a small fraction of hospital care but about 10 to 15% of ambulatory expenses, including drugs. This has allowed the French to avoid rationing as those who can afford it, prefer to pay the premiums. In 2001, 87% of the population had such insurance.

The basic principle of French healthcare is avance de frais, or payment directly from patient to doctor. The freedoms of personal payment, freedom to choose a doctor and the doctor’s freedom to practice, are fundamental to the French system. The patient is reimbursed by insurance, 80% by Securite Sociale, and the rest by assurance complementaire but the principle is supported by the French when they are surveyed and they are suspicious of “free care” as wasteful and liable to abuse.

to be continued:

This entry was posted on Thursday, May 15th, 2008 at 6:58 pm and is filed under health reform. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.