The French Health care system: Liberal Universalism

1. 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

2. 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

3. 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.

4. 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.

5. 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

6. A generous healthcare system

7. 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.

8. Financing • Public/private share unchanged 1995-2006 despite lower reimbursement for medicines. • +78 % public, -9% out of pocket, 13 % complementary insurance, mainly non-for-profit. • Very small market fringe for for-profit HI • Slight growth of employer-sponsored supplementary HI (careful privatization).

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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... ...

15. THANK YOU for your attention